Open Letter to the Board of the Global Fund to fight AIDS, Tuberculosis, and Malaria

To all Members,

Board of Directors, the Global Fund to fight AIDS, Tuberculosis, and Malaria (GFATM):

People living with HIV/AIDS, their allies, and experts around the world will be monitoring closely the outcomes of this second, pivotal Board meeting of the GFATM.

This letter sets out several concerns held by our organizations regarding outstanding policy issues that will come before you for consideration and action during the 22-24 April meeting.

We insist on a concerted effort on the part of this Board to correct and redress the devastating cumulative impact of years of indifference to untreated HIV/AIDS in developing countries, where 95% of people with HIV/AIDS live.

The Board must emerge with a clear statement prioritizing massive scale-up and implementation of antiretroviral treatment programs in developing countries.

The acute need for more money for the GFATM must not be reserved for internal, hushed Board discussion. On the contrary, the desperate need for more resources must be publicly emphasized by the Board. Bona fide demand for funding–especially funding for programs that include antiretroviral treatment, on the scale necessary for substantial impact–tremendously outpaces the funds available to the Board for spending for the first and subsequent tranches of 2002.

This gross lack of resources is an untenable situation that can either be corrected through advocacy and appeal on the part of the Board, or can be tacitly endorsed by the Board through its inaction.

Without swift and decisive action in these areas, the GFATM will become defined to potential contributors and other influential actors as another irrelevant mechanism supporting only slow, incremental shifts in international response to the global AIDS disaster–contradicting the consumer-led demand for affordable AIDS drugs that energized leaders to create the GFATM.

HIV treatment access is a human rights and public health necessity. As a new, non-duplicative mechanism that includes funding HIV treatment programs among its objectives, the GFATM at its launch was seen as the best hope for sustainable, accelerated scale-up and implementation of antiretroviral treatment programs in developing countries.

However, applicants and potential applicants have received mixed messages from the board and from bilateral donors regarding proposals that include funding requests for antiretroviral treatment. When the historical exclusion of treatment was coupled with donor pressure to scale back the size and scope of proposals at the Country Coordinating Mechanism (CCM) level, many countries chose to submit proposals with very modest treatment components, that under-represented the capacity of a country to deliver medicines for AIDS, tuberculosis, and malaria treatment.

The GFATM as a multi-disease entity is constructed to fund a range of interventions, which require a range of costs. In the traditional language of "cost-effectiveness," antiretroviral treatment programs will always be eclipsed by less costly interventions such as HIV prevention, or the treatment and prevention of other infectious diseases. This is unacceptable. Applicants and potential applicants therefore require clear information and guidance about how this Board will prioritize funding among AIDS, tuberculosis and malaria, and among public health responses such as prevention and treatment.

If the GFATM is to take up its task of remedying the disparity in HIV treatment access, the Board must clarify through a public communication that viable antiretroviral treatment programs are feasible, fundable, are a required aspect of a comprehensive, effective response to the AIDS pandemic. Funding requests containing components for AIDS treatment must not be downgraded in consideration because of relative higher cost.

The direct and measurable impact of treatment access on morbidity and mortality, as well as its spillover benefits to HIV prevention efforts, are outcomes necessary to demonstrate for donors the value and impact of GFATM funded interventions. The most dramatic outcomes possible with the scarce resources available will be produced by funding discrete sectors with antiretroviral treatment, effectively delivered.

The Board should encourage exactly such applications, and commit all available resources on hand.

Commitment to the procurement of lowest possible cost, quality medicines–including quality generic drugs–must be communicated by Board members.

Generic competition has been shown to be the most powerful tool in exerting downward pressure on drug prices. The procurement of quality generic versions of HIV medicines will increase life-extending treatment access by extending finite resources as efficiently as possible.

In most developing countries, there is little viable market for pharmaceuticals. Given the decimation of adult populations in some countries due to untreated HIV disease, the interest of brand name pharmaceutical companies in guarding patent monopolies and concomitant high prices must not determine the policy of the Board regarding health commodities procurement.

We note with concern the application submitted by the government of Malawi, where the cost of antiretroviral drugs was calculated based on the reference of proprietary medicines, as per "consultations with WHO and the donor community and initial documents from the Technical Support Secretariat." It is incumbent on the Board to clarify immediately the potential benefits of the use of lowest cost, generic versions of HIV medicines.

The declaration at the World Trade Organization (WTO) Ministerial at Doha, Qatar clarified the right of WTO Member States to utilize safeguards in international trade agreements medicines to achieve public health goals, such as increasing access to affordable HIV medicines. In addition, the recent list published by the World Health Organizations Essential Drugs and Monitoring Project of initial "pre-qualified" HIV medicines suppliers includes generic products.

Consistent with these and other recent favorable policy developments, the Board must publicly state its support for the procurement of quality generic antiretroviral and other medicines, as a policy of amplifying the impact of the finite resources of the GFATM.

The GFATM is not the appropriate venue to interpret or enforce international trade agreements. There are bi- and multilateral fora established to concerns that arise regarding intellectual property rights. The GFATM has no reason to include itself in these discussions.

By any estimation the GFATM is being starved of the resources necessary to mount an effective response to the global AIDS disaster. The gap in resources is clearly the result of rich countries’ decision not to invest significant resources in the GFATM. Several of the world’s wealthiest countries have donated the least to the GFATM as a percentage of overall country wealth. For example, in 2002 Rwanda’s contribution was 10 times as generous as the United States’, when contributions are measured as a proportion of total country wealth.

The Board should play a critical role in transforming the kind words of wealthy countries into action. Lack of funds is blunting the impact of the GFATM. The Board must call on wealthy countries to contribute the billions of dollars needed in new contributions, primarily to fund HIV treatment access.

As the board meeting takes place, activists and elected officials in the U.S. are campaigning for an additional $750 million contribution from the United States for 2002 through an emergency supplemental spending bill now before the U.S. Congress. If successful, this would increase the U.S. contribution to approximately $1 billion for 2002, leveraging additional donations from donor countries and others. Thus far, every dollar contributed by the U.S. has been matched more than fourfold.

Until very recently, antiretroviral treatment programs in developing countries have been ineligible for funding by most donor countries’ assistance programs. Regardless of political commitment at the country level, developing countries have little-to-no experience in composing comprehensive and accurate grant applications that include provisions for establishing or scaling up antiretroviral treatment access programs.

Supporting applicants in their efforts to secure funds for treatment requires not only unequivocal endorsement of the importance of antiretroviral treatment, but also requires that the GFATM extend technical assistance to applicants. Without this provision, applicants will consistently be rejected for funding not for lack of need or capacity, but for lack of guidance. The Board must quickly develop a basic plan for providing technical assistance, in order to increase the facility with which applicants can complete fundable proposals.

A tenet of the GFATM is transparency in operations. In our experience people with HIV and their allies in developing countries have had extreme difficulty in getting even basic questions answered and comments addressed regarding their CCMs completing applications. We see this as a significant problem, as the expertise of people with HIV, their loved ones and care providers are those often best situated to asses the needs of impacted populations. Disregarding or excluding such participation can lead to corruption and ineffectiveness.

The Board must not disregard these concerns–conditions at the country level which exclude the substantive participation of people with HIV only worsen the crisis in lack of access to AIDS treatment. Therefore the Board must facilitate involvement of people with HIV in their CCMs, and must rigorously and publicly investigate complaints regarding the exclusion people with HIV.

We also call on this Board to require each applicant to submit a brief summary of the content of their funding request, for public consumption and posting to the GFATM website. This simple step would increase accountability of governments to civil society. In addition, such a measure would go a great distance to address concerns of donors.

Given the relatively poor outcomes of extant interventions that have been restricted to palliative care and prevention, and the international demand from people living with HIV for fulfillment of the human right to affordable AIDS medicines, the Board must take leadership by affirming the need for expanded antiretroviral treatment access and calling for dramatic increases in contributions to the GFATM.

During this meeting, the GFATM will establish itself either as a crucial mechanism, or as an entity making untenable decisions in the midst of an ever-worsening crisis. Your decisions next week will have far-reaching impact, and as such they will be closely monitored by people living with HIV/AIDS and their allies.

Sincerely,

Asia Russell

Coordinator, International Advocacy

+1 267.475.2645 tel

Gaëlle Krikorian

Coordinator, North/South Commission

Act Up-Paris, France

+3 360.9 17.7055 tel

Kim Nichols, Sc.M., MPH,

Development and Policy Director

African Services Committee

New York City, USA

+1 917.415.3505 tel

cc: GFATM Technical Review Panel (TRP)

GFATM Technical Support Secretariat (TSS)