RF: Because of the Applications That Have Been Made to Us, and These Are Applications By
UK All Party Parliamentary Group on Population, Development
and Reproductive Health Hearings 19th – 20th April 2004.
Richard Feacheem, Executive Director, Global Fund on HIV/Aids, TB and Malaria, was unable to attend the UK Parliamentary Hearings on Reproductive Health and HIV/AIDS but agreed to be interviewed on the subject on a future date. An interview was organised for 5th May 2004.
Tony Worthington MP (RW) and Advisor Ann Mette Kjaerby (AMK) met with Dr Richard Feachaem (RF) on 5th May 2004. The interview was taped and below you will find a transcript of the interview.
RF:
We are sitting here in my office in Geneva, and have just had a chance to look at the Montreau statement on linkages of family planning and the prevention of mother -to -child transmission of HIV.
My response is positive, I think the issues it draws attention to, the specific recommendations,of the statement bboth about programmatic issues and about research agendas,are right on target. There are clearly strong linkages between reproductive health and the control and treatment of HIV/AIDS, those linkages have not been fully drawn out or acted upon, programmatically, or in research terms, and the findings of this meeting are to be welcomed.
TW:
Obviously, that is very welcome, as I was part of the drafting committee. If we can go into the Global Fund’s activities, and its own programmes.
I have been reading the aAnnual rReport, and other Global Fund documents, and what is very striking to me is the lack of reference to the area of Reproductive Health. I went through the aAnnual rReport, and it is very useful but I couldn’t find the phrase, reproductive health or family planning, I wonder whether you are conscious of that?
RF:
Well, no. You are correct; I have not read it looking for those words. I think an important backdrop to this discussion is the deliberate passiveness of the Global Fund with regard to content. I think it bears restatement, the Global Fund was established to be an innovative development finance instrument, and there are several dimensions to this.
A very significant aspect of this is that we deliberately have no hands on in poor countries. When, for example,Malawi applies to the Global Fund for funding, we have no influence on their proposal. iIt is prepared by the CCM. If they decide to apply for HIV/AIDS funding, they may apply for prevention, testing, treatment, orphans or . Ffor programmes that may link more strongly with RH efforts. , wWe,however,have no opinion on that, and we do not influence it in any way at all.
This is a radical experiment. We have never had a development financing organisation that is so passive, that is standing back from the content of what it is we are meant to be financing. It is deliberate, not an oversight, we regard it as an article of faith at the Global Fund, and we stick to it religiously.
We have now had three funding rounds completed as you know. , wWe will soon be reviewing the fourth round,; it is $7billion application to the Global Fund. Therefore, the portfolio is about to expand again, but the current portfolio, which is 225 programmes, in 121 countrieshas balance and distribution that we can readily see. With 60% in Africa and 40% elsewhere, 60% for AIDS, 20% for TB and 20% for malaria.
Within HIV/AIDS there is a very wide spread of investment is in prevention, testing,treatmentand orphans,; pretty much everything you can think of that is scientifically valid, and programmatically confirmed by experience in the field of HIV/AIDS.
Funding is entirely demand driven; we do not have a view of how funding should be allocated.
We do, however,have a duty to ensure that the overall portfolio is balanced. We have a duty to report this and to become concerned if the programme becomes distorted in some way.
Up until now, the good news is that the portfolio turns out to be about right, without us taking any deliberate measures to steer it.
Now your next question is going to be now within that what is the the RH spending, on the interface between RH programmes and HIV/AIDS, and the answer is I don’t know. I don’t think we have broken down the data in that way. It would be a very good question to answer.
We have a new IT system computer programme tthat will allow us to answer questions of that nature in an ongoing way. What we have approved and what we are spending, what things look like segment by segment within HIV/AIDS, TB and Mmalaria? Right now, however, we do not have that those data.
TW:
Do you have any memory of any projects that have had a focus that are about integrating the links and works of the worlds of RH and HIV/AIDS?
RF:
I should have asked my colleagues, but I don’t have any of that in my head. , but mMy very strong hunch would be yes.
TW:
In Montreau we heard criticisms from NGO’s saying that RH issue were sort of excluded from the Global Health Fund, whether that is because they haven’t applied or they haven’tgone through the right route. I do not know. I can understand that what we need is country ownership, a northern NGO coming in from the side, independently, not coming up through Malawi or Uganda programmes, would not have much chance. So part of the answer to this, is that there is not prohibition to building links between RH and HIV/AIDS, but you have got to come through the right way, is that correct?
RF:
Yes, I think that is absolutely right. There are two essentials here, tThe door to the Global Fund is the CCM, country by country, and that has some draw backs and we are aware of that. So tThe who topic of CCMs as the gatekeepers of Global Fund resources and funds in each country is very controversial.
My personal view is that CCMs have been a success, and that where they have weaknesses, we should work to improve them, not go round them, or subvert them.
TW:
What are the weaknesses?
RF:
The crucial one is Government capture, and closing of doors to NGO’s who we are very keen to fund, and we do substantially. , sSo it’s a lack of inclusiveness in terms of the public sector and the private sector that is the systemic issue regarding CCM’s. I am not aware of any issue with CCMs in terms of not favouring, or holding at arms lengththe proposals that would make the link between RH and HIV/AIDS services.
The second point isthat an application that comes in under the banner of a RH application is not likely to succeed through the Global Fund process of screening. It has to be an HIV/AIDS programme, where but within that provided the cthe central purpose of the funding is for the treatment and prevention of HIV/AIDS. Wwe know that this embraces a wide is very plural array of activities, and , then the door is wide open to any and all of those activities. Provided only they are well thought out and consistent with evidence from the field about what works and what doesn’t.
TW:
See, this is my view, I welcome being contradicted, here you’ve got these central organisations, these global organisations, like WHO, UNFPA, who are now getting together, and agreeing they have missed a trick here, the linkage betweenHIV/AIDS and RH. We discussed this matter, you have to see Africa as a terrible failure, in terms of the response of the world and the response of Africa nations to a terrible threat, and we cannot have success in other countries and continents that are under threat unless we change something radically.
One of the areas that I think we need to change is in terms of recognising the links, in our paper we said one of the reasons it went wrong was that northern assumptions about AIDS/HIV, is to do with men who have sex with men, intravenous drug users. This shaped the way we went to Africa, and if we had seenHIV/AIDS as a sexually transmitted disease that was increasingly going to affect women, we would have started from adifferent approach.
RF:
Yes, I wouldthink by the mid 80’s we hadn’t really been paying attention. , bBy the late 80’s we knew enough to understand that this was going to be globally a heterosexual disease, and that the mainstream HIV/AIDS epidemic and the vast majority of infected people in most countries, would be infected through heterosexual sex.
There would be Mmen who have Ssex with mMenepidemic everywhere, and a drug user epidemic, and mother -to -child, and there would be a hospital and transfusionepidemic. But the big one would be heterosexual,and it would quite likely havewhich might suggested different approaches and starting points from those we adopted.
What we now see in Africa, India, Russian, and China, is the extraordinary degree to which this is becoming a young woman’sepidemic. I think that is something horrific in its magnitude. I was recently in Kenyaat a site where they had been collecting really good data, and the infection rate in teenagegirls was 23%, incredible, and the infection rate amongst boys of the same age and community was 4%, which isare devastating figures.
Thisteenage girls and young womaen dimension to this epidemic,epidemicmay stem from thesociological abuse,involuntary sex, and lack of empowerment. In addition,if theseas theseyoung women are sexually active and are becoming , they are getting pregnant, the whole of RH dimensionneeds to be stronger. to this could mean a stronger set of connections. We are now seeing another really important dimension of the epidemic, we are beginning to realise this because of the advent of treatment….HIV/AIDS is a disaster; nothing prepared us for it…….
Another important The other side of that coin is that the way to respond effectively is to normalize mainstream tthe response, by scaling up testing and and as we see tretreatment programmes. starting up and testing, we see the way that normalising things, this This is a virus, I go to a clinic, I get a test, now I am positive, now I take pills, they keep me alive for a long time. , but I am not quire sure how long.I go back to work. My children are not orphaned.
The positive power of that, making it another disease, rather than a mysterious curse of gGod, is hugely powerful in terms of facilitating a response and the effects of treatment on reducing stigma are going to be enormous., within that general idea of making it mainstream, within health service delivery programmes linking with other delivery programmes.
TW:
We cannot really argue. Going back to my initial point, if there are no applications from developing countries, looking at how that fight against aids AIDS can be facilitated by links with Reproductive Health, that is a reflection of the global misperception. The wealthy world tends to shape a lot of areas, and the developing world when they are constructing their approach to HIV/AIDS needs to be helped to see the Reproductive Health links, so that it comes in their packages, and that is the right way to deal with it, because of the advantages of having country ownership?
RF:
Perhaps, I am not completely sure about that. As I mentioned before, what we have foundfund is what countries and organisations bring to us. So aApplicants, particularly the smaller countries with the weaker infrastructure, receive advice from our partners, from DfID, WHO, London School of Hygiene and Tropical Medicine and experts in the respectivecountries. Thereyis an interacting with thoese applicants, who have influence,and are partwho are generally welcomed, and part of the process of developing applications.
The fact is that uUp until now, the applications certainly have not emphasised theseRH linkages, and they have I am sure it is in there somewhere, I am sure it is also true to say it is not in any way a significant part of what we are funding, it has not been prominent in the applications. Is that because of your hypothesis, that we the wWest, have brought an approach to this that may have not been the best one, and has not emphasised those linkages? Or is it because of a different dynamic, which is simply the sense of overwhelming emergency and disaster.
If you sit in an African country, you see the tidal wave of death and destructionbreaking over you, the daily funerals and deaths of relatives and colleagues. You have now come to terms with the nature of this disaster and for the first time in decades you are saying we need a huge national counter -attack, a huge national response, because it is not going to go away. It is not just a problem for foreigners or gay men, it is our problem, and it is huge and it is mainstream.
Suddenly here is the Global Fund standing ready to finance ourideas and our programmes. With very substantial money that has not been available before. , wWhat would you first emphasise? Linkages, which are maybe operationally complex to achieve? Or would you fist emphasise firstly a let’s get the huge blblitz on prevention. going. Every opportunity, TV, billboards, every speech by the Prime Minister, HIV, HIV, HIV, HIV, and a prevention blitz, within that a focus on the high risk groups; , lots of that; plus scaling up testing rapidly, and beginning to make treatment and access to treatment a serious proposition, for the average man and woman, not just the wealthy few.
You wouldmight go into this, blitzkrieg, counter -attack mentality, and think not of linkages, but of the a huge effort focussed on HIV/AIDS. You would come to the subtleties later down the lineon. Because so little is coming in was happening as of the late 90’s, so little prevention, and zero treatment, starting from scratch on treatment. Tthat might have beenyour logical response. the logic.
TW:
You mentioned in your response to the questionnaire, where it says planning and funding Sexual + Reproductive Health and HIV/AIDS joint programmes have the risk of reducing the fight against HIV/AIDS from the state of high alert to business as usual. I can see that, but I think the discovery of Anti Retro Viral drugs, and the ability to control Aids AIDS has put a lot of emphasis on treatment.
I remember going to Botswana, and going to the diamond mines there, they were saying how treatment had transformed the situation into trying to control it; people believe that there is a point in coming to the doctor, whereas before it was a death sentence. But my perception of Montreau and the meeting there is that the emphasis has gone very much to treatment, and the focus has gone off prevention, rather than, as you described, for the great bulk of the world, if we are going to control this thing, it is prevention that has to work, even with Aanti Rretro Vvirals.
How do you perceive that?
RF:
Well, it is certainly true that in the last year, stimulated considerably by the 3 by 5 campaign which we are partners to, along side WHO and UNAIDS, much of the talk is focussed on treatment. However, you are right, prevention remains absolutely the central priority and the Global Fund’s investments are still much mmore in prevention than in treatment as of today. It will shift toward treatment as a result of round 4, but we will certainly have amaintain our commitment to very strongly supporting prevention. approaches.
Secondly, the right balance depends on who ere you are. , iIf you are in Botswana, you just have to give an equal attention to prevention and treatment, because the tide of such and dying individuals is so large, and has such a negative pressures on every aspect of society.
If you are in India, your first duty is to prevent an epidemic that is growing very rapidly. as opposed to an African state of emergency, but atAt the same time India has to develop a plan for effective treatment. Today, for example, there is no wide access for thepoor or lower -middle class to treatment, and that must change.
Thirdly, I am quite convinced that as treatment becomes more available, prevention will go from strength to strength. It will be easier to talk about it, there will be less stigma, there will be more tendency to come forward and be tested. , and pPrevention is greatly assisted by people knowing thereir status. , well oOver 90% of people who are positive do not know that they have HIV.
I think tTreatment and prevention therefore go hand -in -hand. Is there a danger that we may take our eye off prevention in the enthusiasm for treatment? Yes, there is that danger. I don’t see that happening now, either in the applications that we are receiving or what I see in countries, but we have to be alert to that problem.
TW:
To take that further, in the response we have had to questionnaires, and from what we heard at the Hearings, where there is unanimity in terms of the responses, well, we asked people which of the activities, and which of the sectors or aspects of work with HIV and reproductive Health would be best, we used the word integrated, but in hindsight we should have said linked. The unanimity was at the prevention stage, it was vital that the HIV/Aids AIDS world and the Reproductive Health world worked together at the prevention stage, because they had access to different people, the message was the same, about safety. However, tended even there not to happen, there would be parallel services rather than linked services. Would you agree with that?