Key issues for the Second Board Meeting of the Global Fund to fight AIDS TB and Malaria

"… there has been a world-wide revolt of public opinion. People no longer accept that the sick and dying, simply because they are poor, should be denied drugs which have transformed the lives of others who are better off." (Annan speech calling for creation of global fund, Abuja OAU meeting 26 April 2001)

Take every possible action to fulfill this promise that so electrified a world exhausted by inequity, suffering and death. The board must leave New York this week with a resolve to prioritize treatment, and issue policy directives prioritizing country-level proposals include substantial ARV projects.

1. Countries have received mixed messages from the global fund on the role of treatment for AIDS and the use of generic medicines. Bilateral agencies participating on CCMs and elsewhere are pressuring countries to discourage treatment components, reduce the size of applications, and prohibit the use of affordable generic medicines. The secretariat has not discouraged this misbehavior. The GFATM Board must put an absolute and decisive stop to politically-driven measures to reduce the size of applications or proposals.
1. The Board should issue clarifying statements on existing policies on treatment and generic medicines and seek to prohibit back-door pressure. The Board should prioritize access to treatment through the most affordable means available.
2. Secretariat pressure on CCMs to knuckle under to red-faced bilateral donors is unacceptable.
3. Country proposals must be evaluated solely on the measure of merit and capacity to deliver results through a plan crafted by a participatory process.
2. The board should clarify that WTO-legal use of quality generics medicines is acceptable.
1. The board and secretariat must not explicitly or implicitly use the GFATM as a tool to circumvent intellectual property provisions under international trade agreements.
2. Where patents are not an issue, or have been legally suspended by a hard hit country, it is a major overstep of the mission of the Global Fund to disallow use of quality affordable generics.
3. The GFATM is not the appropriate venue to interpret or enforce international trade agreements. If such an issue arises, there are bi- and multilateral fora established to address these questions. It is outside the scope and expertise of the Global Fund to supercede the letter or the spirit of the Doha Declaration on TRIPS and Public Health.
4. The Global Fund must take steps to prohibit such pressure at the CCM level.
3. At this critical start up juncture, the board must declare that access to AIDS treatment is a priority criteria in grant decisions.
1. Clarity of purpose and statement is necessary to correct the historic record of discouraging treatment in impoverished nations be remedied.
2. The Fund recommends "comprehensive approaches" that include prevention, infrastructure development, care, poverty alleviation, and health systems strengthening. The Board needs to send a clear message: the Global Fund is an emergency response to a crisis situation. The Global Fund is not a general development assistance program. The largest premise and promise of the global fund is based on getting medicine to the millions who will die without.
4. The Global Fund should take an active role in fundraising, and immediately disburse every penny on hand to save lives now. Need and high quality proposals have dramatically outpaced meager contributions. Sustaining an inadequate number of small proposals will not generate the necessary contributions to the fund. Only bold action and a vision for growth will inspire investments.
1. The Fund should spend all monies available on hand in this tranche, emphasizing the extent to which the needs far outstrips funds available. The Fund must not heed implicit or explicit political pressure from donors embarrassed over stingy contributions.
2. The Fund should not reject good proposals while there is a single dollar left in the bank.
3. Board media presentations -- beginning Thursday -- should detail the cost in lives of rejecting proposals due to lack of resources.
5. Fund transparency must increase, to increase the confidence of donors, as well as to enhance participation at the CCM level.
1. Board should establish grievance procedures to resolve complaints of untoward pressure by donors/UN agencies or secretariat staff and/or exclusion of civil society at the level of the CCM.
2. The Fund should publish summaries of Fund applications on their website
6. The Secretariat must issue policy statements prioritizing access to treatment.

Some perceive that the board has delivered mixed messages on the question of access to treatment. Indeed, some board delegations have spoken strongly against ARV treatment during TWG meetings.

7. The Board needs basic information on HIV/AIDS, TB, and Malaria. Too many board members in the past have misunderstood that:

1. All 40 million people with HIV do not need medicine. Perhaps 5 million need treatment immediately at any given moment. Medicine can be delivered to most of these people in just a few years with modest investments.
2. Most AIDS medications do not require onerous refrigeration, nor must people with AIDS suffer through outlandish pill burdens. The standard-of -care in wealthier nations is to delay initiation of therapy until symptoms manifest or HIV blood counts are high. At this point, state-of-the-art care is to start therapy with one or two combination pills, taken once or twice a day.
3. Delivering medicine and training to people in need for even a decade will dramatically slow the dying until eagerly awaited promising therapeutic vaccine research seems likely to bear fruit. To buy this decade, the Board should declare unapologetically that putting medicine into the hands of the sick and the poor is central to the mission of the Global Fund, and must be the highest priority during this critical start up phase -- when all eyes are looking for results.

1. Require a truly comprehensive approach.
1. Additionality? Prevention works better with Treatment. If the Fund is intended to be complementary to other existing programs, then filling the programmatic gaps should be the highest priority. National and bilateral prevention programs have already been established in many nations, with good results being generated in Uganda, Senegal, Thailand, and Brazil.
2. Treatment is the largest gap for most nations -- the crucial component of an effective largely response missing from bilateral assistance programs. For the Fund to fulfill its promise, significant treatment components should be a requirement of any application package from any CCM .
2. Nothing delivers results like Tx

As long as the Fund seems satisfied with moderate steps towards broad poverty alleviation and general health systems enhancement, it will be difficult to attain significant measurable results that will inspire the contribution needed to intervene in a major global health disaster.

1. The most dramatic outcomes possible with the scarce resources available will be produced by saturating a measurable discreet sector with effectively delivered antiretroviral treatment.

• If a single large mission hospital or work place program delivers a credible proposal to provide a full range of care services to 1000 people with AIDS, then within a single year, rates of death will decline by 30-50% or greater.

• There will also be a corresponding enhancement in efficacy of prevention efforts, although this can take more than 12 months to take hold.

2. Many suspicious donors are watching the first round of disbursement very closely.
3. Until we can deliver dramatic results such as large declines in rates of death and new infection, then the Fund will have difficulty attracting the resources needed to fulfill its mission.