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Policy brief

Fulfilling the promise to ‘make AIDS history’: Why the UK Government should continue to support the HIV response in middle-income countries Executive Summary Fifteen years ago, two thirds of all people living with HIV resided in low-income countries. The economic status of many countries most affected by the HIV pandemic has since changed. Today 58% of HIV positive people live in middle-income countries (MICs), and by 2020 that proportion is expected to rise to 70%. Of the five countries with the highest HIV burdens globally, three (South Africa, Nigeria and India) are middle-income. Despite this contextual shift to the HIV pandemic, the Department for International Development (DfID) is cutting bilateral HIV funding to MICs. DfID argue that they will now support MICs through the Global Fund to Fight AIDS, TB and Malaria (Global Fund). Yet in reality, Global Fund financing for MICs is also shrinking. For more than 30 years, the UK Government has been at the vanguard of the global response to HIV and AIDS at home and abroad by championing a response to HIV that is evidence-based, focuses on public health, and champions the rights of those most vulnerable to HIV. The UK Government has provided invaluable political leadership, funding, and essential technical support to secure and help to realise a commitment to ending AIDS. The UK Government’s actions have helped to achieve substantial results, most recently driven by a global commitment to universal access. However, the withdrawal of essential funding from MICs places at risk the hard fought for gains made in the global response to HIV and AIDS. At a time when the global community is turning its attention to global sustainable development goals for the post-Millennium Development Goals (MDGs) era, the shift away from MICs chips away at the legacy left by the MDGs. We welcome the UK Governments’ recent recognition that a country’s income status is ‘[not on its own] an adequate guide for [the UK Government’s] allocations’. However, we urge DfID to do more to protect and build upon the successes already achieved in MICs in response to HIV and AIDS. We particularly urge DfID to:

About the International HIV/AIDS Alliance We are an innovative alliance of nationally based, independent, civil society organisations united by our vision of a world without AIDS. Acknowledgements Fionnuala Murphy (lead author), Mike Podmore (lead author), Anton Ofield-Kerr, Susie McLean, Olga Golichenko, Leila Zadeh, Nick Corby. Unless otherwise stated, the appearance of individuals in this publication gives no indication of either sexuality or HIV status.

International HIV/AIDS Alliance 91-101 Davigdor Road Hove, East Sussex BN3 1RE United Kingdom Tel: +44 1273 718 900 Fax: +44 1273 718 901 Email: mail@aidsalliance.org Registered charity number 1038860

www.aidsalliance.org

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 Use the UK’s position on the Global Fund Board to champion, not undermine, adequate funding for the HIV response in MICs and to secure a strong commitment by the Global Fund to scale up services for key populations.  Lay out a clear timeframe for the completion of a ‘development finance strategic framework’ that was committed to in the Government’s response to the first phase of the International Development Committee’s inquiry into the future of development cooperation. Ensure that the framework includes allocation criteria and financing instruments that enable the needs of key populations to be met.  In countries where DfID withdraws bilateral aid, work with the FCO to develop a robust transition plan, in coordination with national governments and other key national stakeholders, to sustain services for key populations until a time that country governments are able to fully support the national HIV response themselves.  Develop a theory of change in close consultation with key population networks and communities addressing HIV among young key populations that explains what DfID wants to achieve and how this will be achieved through a combination of approaches and development interventions.  Develop a strategy and funding mechanism to support LGBT equality to defend the human rights of key populations, and counter the rise of state-sponsored homophobia and transphobia.  Work with the FCO to maximise the contribution of the Commonwealth institutions and the Commonwealth Charter to ongoing efforts to repeal discriminatory and punitive laws, including at the 2015 Commonwealth Heads of Government Meeting in Malta.  Continue and scale up investments to strengthen civil society organisations, particularly in MICs and in settings where governments continue to neglect key populations.  Continue to protect access to affordable generic drugs for MICs so that MICs can continue to scale up affordable treatment for HIV and related illnesses.  Maintain global leadership on harm reduction by continuing to invest in harm reduction programmes through the Global Fund and bilateral aid mechanisms, and continue to champion harm reduction as an evidence-driven response with national governments and multinational institutions.

Introduction

Fifteen years ago, two thirds of all people living with HIV resided in low-income countries1. The economic status of many countries most affected by the HIV pandemic has since changed. Today 58% of HIV positive people live in middle-income countries (MICs), and by 2020 that proportion is expected to rise to 70%2. Of the five countries with the highest HIV burdens globally, three (South Africa, Nigeria and India) are middle-income3. Some MICs have far lower rates of antiretroviral (ARV) coverage for people living with HIV than low-income countries, and much higher rates of multi-drug resistant tuberculosis. In Nigeria, a middle-income country, 32% of people living with HIV and eligible for ARVs are receiving treatment4. In Niger and Benin, neighbouring low-income countries, 46% and 67% respectively of people living with HIV and eligible for ARVs are receiving treatment5. 1. Presentation by Bernhard Schwartländer, Director of Evidence, Innovation and Policy at UNAIDS, to the International AIDS Conference in Washington, D.C. in July 2012. Available at http://www.cegaa.org/resources/docs/IAC/What_will_it_take_to_turn_the_tide.pdf 2. Presentation by Bernhard Schwartländer, Director of Evidence, Innovation and Policy at UNAIDS, to the International AIDS Conference in Washington, D.C. in July 2012. Available at http://www.cegaa.org/resources/docs/IAC/What_will_it_take_to_turn_the_tide.pdf 3.Glasman A., Duran D., and Sumner A., Global Health and the New Bottom Billion: What Do Shifts in Global Poverty and the Global Disease Burden Mean for GAVI and the Global Fund?, Working Paper 270 (2011). Available at http://www.cgdev.org/publication/global-health-and-new-bottom-billion-what-do-shifts-global-poverty-and-global-disease. 4. Antiretroviral therapy coverage among people with HIV infection eligible for ART according to 2010 guidelines (%). Data taken from the World Health Organisation Global Health Observatory Data Repository (http://apps.who.int/gho/data/node.main.626?lang=en) , 20 May 2014. 5. Antiretroviral therapy coverage among people with HIV infection eligible for ART according to 2010 guidelines (%). Data taken from the World Health Organisation Global Health Observatory Data Repository (http://apps.who.int/gho/data/node.main.626?lang=en) , 20 May 2014.

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MARI project, Warangal. Dawood and partner Ramesh. © Jenny Matthews

Despite this contextual shift to the HIV pandemic, the Department for International Development (DfID) is cutting bilateral HIV funding to MICs. Following its bilateral aid review in 2011, DfID decided to end bilateral aid programmes in 16 countries, most of them MICs6. The UK has since announced further plans to terminate bilateral aid to South Africa and India7. Sadly DfID’s bilateral HIV programming has not escaped this trend. DfID’s latest position paper on HIV reveals that in 2012/13 DfID provided bilateral HIV funding in 16 countries, compared to 26 countries in 2010/118. This number will drop further still in the next two years as DfID HIV programmes close in Bangladesh, Cambodia, India, South Africa and Vietnam9. Apart from their programme in Burma, all of DfID’s HIV programmes in Asia have now closed or are set to close in the near future. Despite reporting success of its harm reduction programmes in Asia, the closure of these programmes mean a 90 per cent drop in UK bilateral support of harm reduction for people who inject drugs. DfID argue that they will now support MICs (and critical work on harm reduction, for example) through the Global Fund to Fight AIDS, TB and Malaria (Global Fund). Yet in reality, Global Fund financing for MICs is also shrinking, influenced by the cut in bilateral HIV funding to MICs. The International HIV/AIDS Alliance is very concerned by these developments. This briefing outlines our concerns, and calls for a strategic approach to HIV funding in MICs which: 1. Supports a coordinated transition towards fuller domestic funding, recognising that not all MICs are ready to fully fund their HIV response. 2. Sustains services for key populations most affected by HIV, and defends their human rights. 3. Continues and scales up investments in civil society organisations. 4. Sustains Global Fund support for the HIV response in MICs. 5. Protects access to affordable generic drugs for MICs. 6. See http://www.publications.parliament.uk/pa/cm201314/cmselect/cmintdev/822/82203.htm 7. See http://www.publications.parliament.uk/pa/cm201314/cmselect/cmintdev/822/82203.htm 8. Department for International Development, Towards zero infections: The UK’s position paper on HIV in the developing world (2011) 9. Countries where bilateral programmes were funded in 2012/13 were Bangladesh, Burma, Cambodia, DRC, Ethiopia, Ghana, India, Kenya, Malawi, Nigeria, Sierra Leone, Republic of South Africa, Uganda, Vietnam, Zambia, Zimbabwe. Department for International Development, Towards zero infections: The UK’s position paper on HIV in the developing world (2011)

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1. Coordinate a transition towards fuller domestic funding Levels of domestic HIV funding have improved significantly since 2005. BRICS countries (Brazil, Russia, India, China and South Africa) increased their domestic HIV funding by 120% between 2006 and 201110. However, some MICs cannot end their national AIDS epidemic on their own, and need continued donor support in order to sustain and scale up their HIV responses. A country becomes middle-income when its Gross National Income (GNI) per capita reaches US$1,000 per year. In their recent paper Do middle-income countries need aid?, Bond notes that many countries at the lower end of the middle-income category are unable to mobilise sufficient taxes to fund their health and development responses, either because unequal income distribution means that not enough people are eligible for taxation or because their national income is just too low11. The Results for Development Institute has estimated that in Zambia, a new lower-MIC, a fully funded HIV response would cost more than 6% of GNI12. Fully funding the national HIV response is beyond the Zambian Government’s financial capacity in the short- or even long-term. Even an upper-MIC, such as South Africa, may not, at least in the short term, be able to fully fund its national HIV response. South Africa has an adult HIV prevalence rate of 17.9% and more than 6 million people living with HIV13. While the country has made critical progress in terms of access to ARVs, the national HIV response is still fragile. A recent Lancet review noted that South Africa made no gains in reducing HIV prevalence among young pregnant women between 2006 and 201214. Although South Africa is transitioning towards a stronger national health programme and is now funding 85% of its national HIV response, the sheer scale of the response needed is a huge challenge to the country’s resources, ensuring that donor support is still important. In November 2012, Secretary of State for International Development Justine Greening announced that the UK would terminate bilateral aid for South Africa by 201515. The Select Committee on International Development has criticised the Secretary of State’s decision on the basis that it was taken just 18 months after the bilateral aid review, which concluded that UK support to South Africa should continue. Following a recent enquiry the Committee wrote that the decision was “neither methodical nor transparent, but related to short term political pressures”16. During the enquiry, the International HIV/AIDS Alliance voiced concerns that the UK’s termination of bilateral aid had been decided without due regard to the needs of South Africa’s national HIV response, a country where almost a quarter of a million people died of AIDS-related illness in 2012. A reduction in aid could delay the scale up of lifesaving ARV treatment and, if not carefully managed, endanger access to ARVs for those who already receive treatment. As the example of South Africa underlines, donors’ approaches to HIV funding need to examine the scale and impact of the country’s HIV epidemic, and the country’s ability to fund the required national response. Donor policy should reflect the reality that any transition in a country’s income status from low- to middleincome does not necessarily translate into a capacity to substantially increase health expenditure, and in particular to fully fund their national HIV response. In countries where DfID plans to terminate bilateral aid 10. UNAIDS Press Statement: More than 80 countries increase their domestic investments for AIDS by over 50% between 2006 and 2011, 18 July 2012. Available at http://www.unaids.org/en/resources/presscentre/pressreleaseandstatementarchive/2012/july/20120718prunaidsreport/ 11. Thomas A., Do middle-income countries need aid? Literature review and analysis of evidence and opinions used in the aid differentiation debate, Bond (2013) 12. Results for development Institute (2010). Costs and choices: Financing the long term fight against AIDS. Available at http://r4d.org/knowledge-center/costs-choices-financing-long-term-fight-against-aids. 13. Data taken from the World Health Organisation Global Health Observatory Data Repository, 20 May 2014. 14. Mayosi B., Lawn J., van Niekerk A., Bradshaw D., Karim S., and Coovadia H., Health in South Africa: changes and challenges since 2009, The Lancet - 8 December 2012 ( Vol. 380, Issue 9858, Pages 2029-2043) 15. Department for International Development Press Release: UK to end direct financial support to South Africa, 30 April 2013. Available at https://www.gov.uk/government/news/uk-to-end-direct-financial-support-to-south-africa 16. House of Commons International Development Committee, The Closure of DFID’s Bilateral Aid Programmes: the case of South Africa (2014). Available at http://www.publications.parliament.uk/pa/cm201314/cmselect/cmintdev/822/822.pdf.

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programmes, the Global Fund can provide support, but DfID should work closely with the Foreign and Commonwealth Office (FCO) to articulate and implement a coordinated transition towards fuller domestic funding in collaboration with MIC country governments and other key national stakeholders. In practice, this may take the form of DfID supporting programmes which ensure continued access to essential services until the government is in a position to take over financially and scale up the programme, at which point DfID might transition to providing technical assistance in order to help the country government implement costeffective national programmes. Supporting countries to develop stronger taxation systems is also a key part of transitioning away from aid in MICs.

2. Sustaining services for key populations and defending their human rights The framework for strategic investment outlined by UNAIDS and others proposes a focus on six basic activities in order to target investments more strategically and effectively. One of the six activities is programming for key populations17, in particular, men who have sex with men (MSM), transgender women, sex workers, and people who use drugs. Many MICs have large populations of key populations, but MIC governments are often unwilling to provide the HIV services key populations specifically need. Even in countries where health and social development rank highly as national priorities, public health services often exclude these key populations and do not provide interventions tailored to their specific needs. International donors have often stepped in to support services for key populations while also seeking to create an enabling environment that empowers the government or civil society to take responsibility for service provision in the long term. In its last HIV strategy in 2008, Achieving Universal Access, DfID pledged to increase coverage of HIV services for people who inject drugs, and supported nine bilateral programmes with a harm reduction component18. One of these nine programmes was based in Vietnam, a country with a concentrated HIV epidemic among people who inject drugs and sex workers. Until 2004, the Vietnamese government’s key approach was to ‘rehabilitate’ these groups by placing them in compulsory detoxification facilities - a practice which proved disastrous both in preventing HIV and from a human rights perspective. In 2003, DfID and the World Bank began supporting a large-scale programme in Vietnam that provided clean needles and syringes to people who use drugs and condoms to sex workers, and provided technical support to the Vietnamese government to help them adopt a more human rights and health-centred approach. Between 2003 and 2012, when the DfID and World Bank programme was implemented, HIV prevalence among people who use drugs in Vietnam fell from 21.3% to 9.6%, and among sex workers from 3.7% to 2.6% thereby averting an estimated 33,000 new infections19. DfID’s latest position paper on HIV pledged to ensure continuity of harm reduction services in Vietnam, by working with the Global Fund, the ‘One UN Fund’ in Vietnam, and the Vietnamese Government20. The evaluation of the DfID and World Bank programme has since noted that Vietnam’s national HIV response remains highly dependent on foreign aid and that with the end of DfID and World Bank funding, it is unlikely that the current national response will be sustained. The programme evaluation also highlights concerns that Vietnam is continuing to incarcerate people who use drugs and that there is still resistance to harm 17. Schwartlander et al, Towards an investment approach for an effective response to HIV/AIDS, Volume 377, Issue 9782, Pages 2031 2041, 11 June 2011. Available at http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)60702-2/abstract. 18. Department for International Development, Achieving Universal Access – the UK’s strategy for halting and reversing the spread of HIV in the developing world (2008). Available at http://www.ilo.org/wcmsp5/groups/public/---ed_protect/---protrav/---ilo_aids/documents/legaldocument/wcms_127511.pdf . 19. Zhang L., Maher L., Pham Q., Higgs P., Anh N., Duc B., Hoa D., and Wilson D., Evaluation of a decade of DFID and World Bank supported HIV and AIDS programmes in Vietnam from 2003 to 2012 (2013). 20. Department for International Development, Towards zero infections –Two years on: A review of the UK’s position paper on HIV in the developing world (2013)

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Ivan Shekker, or ‘Vanya’, manager of one of the largest injecting drug use (IDU) harm reduction projects in Ukraine, implemented by the Eney Club in Kyiv. On August 17, 2010, Ivan died from cancer. © Gideon Mendel for the Alliance

reduction among the government and law enforcers. The programme evaluation recommends that DFID maintain an advisory role. It is essential that DfID articulates a clear and robust plan, in coordination with national governments and other key national stakeholders, in countries where it withdraws bilateral aid, to ensure continued access to essential services until a time that country governments are able to fully support the national HIV response themselves. Romania’s experience highlights the important role DfID can continue to play, but also the importance of carefully managing any transition from donor to domestic funding. When Romania became ineligible for Global Fund resources in 2010, no transitional arrangements were secured for existing harm reduction programmes run by non-governmental organisations, and the Government failed to support the programmes. In 2010 alone, the percentage of people who inject drugs reached by harm reduction programmes decreased from 76% to 49%, and in 2011, the number of new HIV infections was higher than in previous years21. A higher proportion of new infections were attributed to drug use in 2011 than in previous years22. Key populations are criminalised in many MICs. This can prevent many individuals from accessing HIV services, even where services exist. Although India’s national HIV strategy includes provision for MSM, for example, the Indian Supreme Court recently reinstated a ban on same sex acts23. HIV prevalence among MSM in India is 7.3%, more than 20 times the national prevalence rate of 0.3%24. Similarly Nigeria 21. Stuikyte R., Votyagov S., and Pinkham S., Quitting while not ahead: The Global Fund’s retrenchment and the looming crisis for harm reduction in Eastern Europe and Central Asia, Eurasion Harm Reduction Network (2012). Available at http://www.harm-reduction.org/sites/default/files/pdf/ehrn_quitting_while_not_ahead_final_july_12.pdf 22. Stuikyte R., Votyagov S., and Pinkham S., Quitting while not ahead: The Global Fund’s retrenchment and the looming crisis for harm reduction in Eastern Europe and Central Asia, Eurasion Harm Reduction Network (2012). Available at http://www.harm-reduction.org/sites/default/files/pdf/ehrn_quitting_while_not_ahead_final_july_12.pdf 23. See for example http://www.bbc.co.uk/news/world-asia-india-25329067 24. Data taken from the World Health Organisation Global Health Observatory Data Repository, 20 May 2014.

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has recently introduced a law banning gay marriage and the public display of same sex relationships25. Individuals prosecuted under this Nigerian law face up to 14 years imprisonment, and anyone providing support to establishments or operations considered “homosexual” also faces up to 10 years imprisonment. HIV prevalence among MSM is estimated to be 17% in Nigeria – more than five times the national prevalence rate of 3.1%26. UNAIDS and the Global Fund have warned that these developments threaten the HIV response in these countries, and the rights of LGBT people27. The FCO has also spoken out against the new law in Nigeria28. The FCO’s vocal criticism of this Nigerian law is commendable, but there is much more that the UK can do. Criminalisation, discrimination and violence against LGBT people is on the increase globally, including in MICs such as Russia and Ukraine. The UK, as a vocal supporter of LGBT people’s human rights, should develop a strategy and funding mechanism to support LGBT equality. The UK should also increase its political leadership on LGBT people’s rights, using all available channels of advocacy and diplomacy to counter the rise of state-sponsored homophobia. Similarly, as hard line governments including Russia seek to advance a tougher agenda on drugs, as evidenced at the 2014 Commission for Narcotic Drugs in Vienna, it is vital that more progressive countries such as the UK do more to champion evidence-informed responses to HIV, and defend harm reduction services at the international level. At the national level, DfID can also play a critical role in supporting MICs to introduce effective HIV services for key populations through the provision of technical expertise and guidance. In addition to championing evidence-informed responses to HIV, the UK can also promote the human rights of key populations by combining DfID’s specialism in international development and governance issues with the human rights expertise of the FCO. The UK could also do more to maximise the contribution of the Commonwealth institutions. The Commonwealth Secretariat for example could use Commonwealth Charter provisions on non-discrimination and evidence-based HIV prevention to argue for the repeal of discriminatory and punitive laws, and should push for progress on these Charter pledges at the 2015 Commonwealth Heads of Government Meeting in Malta. As a starting point, the Commonwealth Secretariat should certainly ensure that its own strategies on health and human rights align closely with DfID and FCO objectives.

3. Scale up investment in civil society organisations A coordinated transition to fuller domestic funding requires a continued and well-financed role for civil society. In many MICs, civil society organisations lead aspects of the HIV response, providing essential services which will disappear if donor funding is withdrawn without ensuring alternative sources of financing. Recent research highlights that civil society is a leading actor in terms of reaching key populations29. The DfID-funded World Bank study, Investing in Communities Achieves Results, shows that civil society organisations play an essential and even more extensive role in the HIV response30. Also, DfID’s position paper, Towards Zero Infections, recognises the vital contribution that civil society organisations make not only in increasing access to services, but also in defending the human rights of people living with HIV and those most affected by HIV, as well as advocating for legal and policy change31.

25. Same Sex Marriage (Prohibition) Act 26. Data taken from the World Health Organisation Global Health Observatory Data Repository, 20 May 2014. 27. See, UNAIDS Press Statement: UNAIDS and the Global Fund express deep concern about the impact of a new law affecting the AIDS response and human rights of LGBT people in Nigeria, 14 January 2014. Available at http://www.unaids.org/en/resources/presscentre/pressreleaseandstatementarchive/2014/january/20140114nigeria/ and UNAIDS Press Statement: UNAIDS calls on India and all countries to repeal laws that criminalize adult consensual same sex sexual conduct, 12 December 2013. Available at http://www.unaids.org/en/resources/presscentre/pressreleaseandstatementarchive/2013/december/20131212psindia/. 28. Foreign and Commonwealth Office Press Statement: Foreign Secretary expresses disappointment with anti-LGBT legislation in Nigeria. Available at https://www.gov.uk/government/news/foreign-secretary-expresses-disappointment-with-anti-lgbt-legislation-in-nigeria 29. Independent Commission for Aid Impact, DFID’s support for civil society organisations through Programme Partnership Agreements (2013) 30. Rodriguez-García R., Bonnel R., Wilson., and N’Jie N., Investing in Communities Achieves Results, Directions in Development - Human Development (2013) 31. Department for International Development, Towards zero infections: The UK’s position paper on HIV in the developing world (2011)

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Case study: Working with civil society to advance human rights and promote access to services for key populations in Latin America In Latin America, the HIV epidemic is concentrated among MSM, sex workers and transgender women. However, most governments in the region do not support a targeted HIV response. Key populations are frequently subject to stigma, violence and other violations of their human rights, which are often committed with impunity32. As a result, financial support targeted towards these key populations is heavily dependent on international aid. In 2008, two International HIV/AIDS Alliance partner organisations, the Latin American Network of Sex Workers (REDTRASEX) and the Latin American Network of Transgender Women (REDLACTRANS), received funding through DfID’s Latin American Partnership Programme Agreement (LAPPA). The two networks used their funding to support national organisations, working with them to document human-rights abuses across the region and to hold state authorities accountable for these abuses.  During the grant period, the networks and their member organisations also gained a greater voice in decision making processes such as Global Fund country coordinating mechanisms. As a result, the networks began to reduce stigma and discrimination by increasing their public visibility. Between 2011 and 2014, REDLACTRANS have spearheaded some vital changes, including a new law in Argentina which enables transgender people to register as their preferred gender and therefore to finally realise legal identity. Efforts to persuade other countries to adopt similar laws are underway, but progress is slow and human-rights violations by both state- and non state-actors continue with impunity.

As the case study above illustrates, DfID’s model for empowering organisations and structures that support populations at higher risk of HIV has proven successful. However, the LAPPA programme was discontinued in 2010. Furthermore, Programme Partnership Agreements (PPAs) are now also under threat, with a decision on their future to be taken in 2016. DfID’s Civil Society Challenge Fund, another key mechanism through which civil society funding is disbursed, is also set to close. While funding for civil society organisations has increased as a proportion of DfID’s bilateral HIV funding (from 21% in 2008/9 to 34% in 2012/13), the total amount of DfID’s bilateral HIV funding has dropped by £75 million since 2010, to around £180 million, and it is set to fall further as more of DfID’s HIV programmes close. DfID’s position paper, Towards Zero Infections, highlights the Robert Carr Fund as a key vehicle for DfID’s civil society financing, but the Fund supports only regional and global networks and not service provision or national and community level advocacy, and the UK’s total pledge is insufficient at just £4 million over three years33. Funding for civil society should remain a key strategy for DfID going forward, particularly in MICs and in settings where governments continue to neglect those at highest risk. In the context of decreasing ODA for MIC governments, funding for civil society organisations that can be most effective at reaching key populations and hold their governments to account will be increasingly important.

4. Sustaining Global Fund support for the HIV response in MICs Based on current trends, the Global Fund will become the key vehicle through which DfID’s HIV funding is disbursed. In July 2013, following the roll out of the Global Fund’s new funding model, the UK pledged up to £1 billion to the Global Fund over three years from 201434. Around £500 million of this money will go to HIV programmes. 32. REDLACTRANS and the International HIV/AIDS Alliance, The night is another country: Impunity and violence against transgender women human rights defenders in Latin America (2013) Available at http://www.aidsalliance.org/publicationsdetails.aspx?id=90623&dm_i=J95,13JE9,35MKJS,3F0N5,1. 33. See http://devtracker.dfid.gov.uk/projects/GB-1-203325/ 34. DFID pledged to give 10% of whatever is pledged globally to the Global Fund over the three years of the replenishment period. This means that if the global target of $15 billion is reached by the end of 2016, DFID will contribute US$1.5 billion / £1 billion.

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In 2011, the Global Fund introduced a ‘55% rule’, which sought to limit financing for programmes in MICs. The International HIV/AIDS Alliance and other organizations successfully appealed to the Global Fund Board to revoke this rule in May 2012, arguing that it was undermining the Global Fund’s ability to target countries with the highest HIV burdens. More recently however, the threat of limited funding from the Global Fund for countries with the highest HIV burdens has returned. The Global Fund is now assigning countries to four bands depending on their overall rates of HIV, TB and Malaria, as well as their capacity to fund national responses. A large number of MICs have been placed in Band D (signifying low disease burden and a greater ability to pay), for which the overall pot of money available is limited. Many of the countries in Band D have significant epidemics among key populations. Like DfID, the Global Fund’s rationale for reducing available funding to MICs is that those countries should fund their own responses. However, as we have discussed above, a country’s income does not necessarily reflect its ability or willingness to pay, especially when it comes to key populations such as MSM, sex workers or people who use drugs. Bilateral funding for services reaching these populations is already drying up and now, Global Fund support is also shrinking. As a result, recent analysis supported by the International HIV/AIDS Alliance illustrates that the Global Fund’s new funding model will result in a funding crisis for essential harm reduction services35. In the Global Fund’s Round 10, 7% of approved HIV funding went to harm reduction. Under the Global Fund’s new funding model, a similar rate of approval would see approximately US$64 million allocated to harm reduction, less than what the Global Fund allocated in Round 1036. To make matters worse, only 10 of the 58 countries that have previously used Global Fund resources for their harm reduction programmes are eligible for incentive funding. For 2015 and 2016, Ukraine will currently be granted less than half what it was granted for harm reduction for 2013 and 2014. The Global Fund is the largest donor for harm reduction programmes. As a result, this dramatic cut in funding will have a devastating effect on service provision. DfID’s latest position paper on HIV recognises the broader problem and states that “the future of Global Fund support in some MICs... requires a robust debate and strategy which the UK will be pursuing with the Global Fund and partners” 37. We believe that as a Global Fund Board Member, DfID needs to take a much stronger stance on how the Global Fund should continue to support the HIV response in MICs. The Global Fund’s approach must reflect the UK Governments’ recent recognition that a country’s income status is ‘[not on its own] an adequate guide for [the UK Government’s] allocations’38. In contrast, the Global Fund’s current approach has been influenced by and mirrors DfID’s withdrawal of HIV funding from MICs. DfID should be careful to steer the Global Fund away from an ever more rigid and formulaic centrally-imposed approach under which funding allocations are capped and limited based on an overly simplistic classification of national income. The International HIV/AIDS Alliance would like to see DfID take steps to ensure that the Global Fund delivers on the fourth objective in its strategy, which focuses on promoting human rights in the programmes it finances, and that the Global Fund’s new funding model helps to support strong HIV responses in MICs. Under the Global Fund’s new funding model, countries’ concept notes are developed or updated based on an iterative dialogue between all stakeholders (particularly including key populations) which works to form the focus of the funding request to the Global Fund. The meaningful inclusion of key populations at every stage of these dialogues will be critical in MICs where there is a significant danger that services tailored to the needs of key populations will be endangered as the focus shifts onto domestic funding. Having made a significant investment in the Global Fund, DfID country offices should play an active role at country level to ensure funding prioritises evidence-based programmes that can demonstrate impact and ensure that the most marginalised are supported to play an active role in funding and programming decisions at country level. 35. Harm Reduction International, International Drug Policy Consortium & International HIV/AIDS Alliance (2014), The funding crisis for harm reduction: Donor retreat, government neglect and the way forward. London: Harm Reduction International. Available at http://www.ihra.net/contents/1447. 36. Presentation by Susie McLean on behalf of International HIV/AIDS Alliance, Harm Reduction International, and International Drug Policy Consortium at the 2nd European Harm Reduction Conference in Basel, 7 May 2014. Available at http://www.harmreduction.ch/en/presentations/. See also Eurasian Harm Reduction Network, Quitting while not ahead: The Global Fund’s Retrenchment and the looming crisis for harm reduction in Eastern Europe and Central Asia (2012) 37. Department for International Development, Towards zero infections – Two years on: A review of the UK’s position paper on HIV in the developing world (2013) 38. See http://www.publications.parliament.uk/pa/cm201314/cmselect/cmintdev/1255/125504.htm

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Nga used be a sex worker. She now delivers outreach to help street sex workers by giving them condoms and sharing experiences. © Mr Thahn, SCDI

5. Protecting access to affordable generic drugs for MICs Over the last decade, the price of first and second line ARVs has dropped significantly, largely as a result of competition among producers of generic medicines. Today, first-line ARV treatment is available for less than US$100 per person per year, a 99% decrease since 200039. The cost of second line ARV treatment has also fallen by about 75%, to around $300 for today’s most affordable second-line combination40. These lower prices have been critical to the scale up of first line ARV treatment in developing countries, and to the roll out of second line treatment as people develop resistance to first line ARVs. Problematically, MICs are under increasing pressure to not utilise flexibilities in international trade rules which allow generic production in limited circumstances. This means that there is no generic competition for newer drugs such as third-line ARVs and salvage treatments. Prices for the newer drugs remain unaffordable for many countries. The problem is particularly pronounced in MICs, which are unable to benefit from price reductions offered by originator companies to the poorest countries. Instead, they have to engage in case-by-case negotiations, which often lead to astronomically high prices. In their 2013 report, Untangling the web of ARV price reductions, Medecins Sans Frontieres highlight three new drugs, raltegravir (RAL), etravirine (ETV) and darunavir (DRV), which are used for third-line ARVs or salvage therapy. There are currently no WHO prequalified generic versions of these drugs, and MICs are paying as much as US$13,213 for RAL, US$6,570 for ETV, and US$8,468 for DRV41. Drugs for common co-infections affecting people living with HIV – notably Hepatitis C – are currently priced at similar levels. Faced with these prices and growing levels of resistance, MICs will find it increasingly difficult to sustain their national HIV responses. DfID has historically been a leader on access to medicines and should continue to support and facilitate generic production of newer medicines, including specific strategies for protecting access in MICs. As a Global Fund Board member, DfID should also ensure that the Global Fund supports a broader and more inclusive MIC-led approach to tackling access to essential medicines. 39. Medicins Sans Frontieres, Untangling the web: Antiretroviral price reductions, 16th Edition – July 2013 (2013) 40. Medicins Sans Frontieres, Untangling the web: Antiretroviral price reductions, 16th Edition – July 2013 (2013) 41. Medicins Sans Frontieres, Untangling the web: Antiretroviral price reductions, 16th Edition – July 2013 (2013)

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Conclusion The International HIV/AIDS Alliance is very concerned that the current emphasis by DfID, and a growing number of other donors, on withdrawing financial support for MICs is likely to significantly undermine the global response to HIV and AIDS. Without a careful and supported transition to domestic funding, the provision of essential services to key populations, as well as efforts to defend their human rights, will almost certainly be undermined. The Alliance calls for a new strategic approach by DfID to HIV funding in MICs. We particularly urge DfID to:  Use the UK’s position on the Global Fund Board to champion, not undermine, adequate funding for the HIV response in MICs and to secure a strong commitment by the Global Fund to scale up services for key populations.  Lay out a clear timeframe for the completion of a ‘development finance strategic framework’ that was committed to in the Government’s response to the first phase of the International Development Committee’s inquiry into the future of development cooperation. Ensure that the framework includes allocation criteria and financing instruments that enable the needs of key populations to be met.  In countries where DfID withdraws bilateral aid, work with the FCO to develop a robust transition plan, in coordination with national governments and other key national stakeholders, to sustain services for key populations until a time that country governments are able to fully support the national HIV response themselves.  Develop a theory of change in close consultation with key population networks and communities addressing HIV among young key populations that explains what DfID wants to achieve and how this will be achieved through a combination of approaches and development interventions.  Develop a strategy and funding mechanism to support LGBT equality to defend the human rights of key populations, and counter the rise of state-sponsored homophobia and transphobia.  Work with the FCO to maximise the contribution of the Commonwealth institutions and the Commonwealth Charter to ongoing efforts to repeal discriminatory and punitive laws, including at the 2015 Commonwealth Heads of Government Meeting in Malta.  Continue and scale up investments to strengthen civil society organisations, particularly in MICs and in settings where governments continue to neglect key populations.  Continue to protect access to affordable generic drugs for MICs so that MICs can continue to scale up affordable treatment for HIV and related illnesses.  Maintain global leadership on harm reduction by continuing to invest in harm reduction programmes through the Global Fund and bilateral aid mechanisms, and continue to champion harm reduction as an evidence-driven response with national governments and multinational institutions.

www.aidsalliance.org

Link Up is an ambitious five-country project to improve the sexual and reproductive health and rights (SRHR) of one million young people most affected by HIV in Bangladesh, Burundi, Ethiopia, Myanmar and Uganda. Launched in 2013 by a consortium of partners led by the International HIV/ AIDS Alliance, Link Up will strengthen the integration of HIV and SRHR programmes and service delivery. It will focus specifically on young men who have sex with men, sex workers, people who use drugs, transgender people, and young women and men living with HIV. For more information, visit www.link-up.org


Policy briefing: Fulfilling the promise to ‘make AIDS history’