Focus on funding at global AIDS conference

United States government officials in general, and Ambassador Randal Tobias in particular, have acted as a magnet for placard-waving activists this week at the 15th International AIDS Conference in Bangkok, Thailand. Tobias heads the US administration's global AIDS policy, whose centrepiece is the US $15 billion President's Emergency Plan for AIDS Relief (PEPFAR), which aims to treat two million HIV-positive people and prevent seven million new infections over a five-year period, mainly in the 15 worst-affected countries. The US government allocated $2.4 billion in 2004 towards those laudable goals. But critics argue that the bilateral initiative diverts urgently needed financing away from the Global Fund to Fight AIDS Tuberculosis and Malaria, and accuse President George Bush of acting in the interests of the pharmaceutical industry. PEPFAR has also been condemned for allegedly pushing an ideological message of abstinence - when that is not an option for many women - and for spending too much on US service providers at the expense of local expertise and capacity. Speaking at the conference on Wednesday, Tobias said it was time to end divisions in the struggle against the epidemic, as "we are all striving towards the same goal - a world free of AIDS". His address, however, was delayed by 15 minutes as activists marched to the foot of the podium with placards that read "He's lying". Tobias' message was that the United States was providing leadership with the single agenda of tackling the epidemic. On antiretrovirals (ARVs), Tobias said he would look at buying cheaper generic copies of brand-name drugs if they were approved by the US Food and Drug Administration (FDA) as there was a "moral imperative" that the ARVs distributed were "safe and effective". The US government has rejected pre-qualification of drugs by the World Health Organisation, but has promised an accelerated FDA certification process, an offer which no generic manufacturer has as yet accepted. "It's a hoax - a decoy strategy," charged Dr Paul Zeitz of the Global AIDS Alliance. "Any generic company would be crazy to submit to FDA approval in this environment of a relentless, multiprong strategy to block access to generic drugs." PEPFAR, launched in 2003, has been a significant new addition to a growing list of international funders, which includes the World Bank's Multi-Country AIDS Programme, the Clinton Foundation, private corporations and the two-year-old Global Fund, set up as a partnership between governments, the private sector and civil society. As the number of funding sources has grown, so has recognition of the need for harmonisation and streamlining of donor procedures to enable better utilisation of grants. The so-called 'three ones' - one national AIDS action plan, one national coordinating strategy, one monitoring system - are key to preventing duplication and identifying bottlenecks to aid flows, according to UNAIDS. Much of the AIDS activists' criticism of the Geneva-based Fund has related to the lack of representation of NGOs and vulnerable groups on the Country Coordinating Mechanisms (CCM) - through which local stakeholders make grant proposals and receive financial support - and the CCM's effectiveness, transparency and independence from governments. But the Global Fund has also been recognised as more than a funding mechanism. "The Fund is rewriting the rules on delivering assistance. It tries to marry the best of all other instruments - an emergency spirit, recipient-owned programmes, and participatory processes", while addressing the problems that have emerged, noted Mabel van Oranje of the Open Society Institute. The local ownership of programmes helps counter what has been described as "donor-driven agendas". "Take PEPFAR for example," said van Oranje in a presentation at the conference reviewing new funding mechanisms. "It earmarks a specific proportion of spending for abstinence-only programmes. "At issue is not only the effectiveness of the 'A' of 'Abstinence' versus the 'B' of 'Being faithful' or the 'C' of using 'Condoms', it is also about whether in-country experts should design programmes shaped by realities on the ground: in Africa many new infections occur in monogamous married women - they are already 'being faithful' and 'abstinence' is just not an option." But the Global Fund is at a critical juncture, needing at least US $1.4 billion in 2004 and $3.4 billion in 2005, according to a report by the International Council of AIDS Service Organisations (ICASO). Only $800 million has been so far pledged towards next year's requirement. Among the demands of chanting activists at the conference has been to "fund the Fund". They have pointed to Bush's allocation of $200 million to the Geneva-based organisation for 2005, the $85 million Germany has promised, and the zero pledge from Japan, as evidence of the failure of key, wealthy countries to commit to what remains a unique grant-making agency. "Donor governments need to view the Global Fund in the same way that they view their other national priorities, like contributions to international peacekeeping, or investments in domestic school systems. The Global Fund must be based on a truly joint and long-term global commitment to financing the war on AIDS, TB and malaria," ICASO urged in its report.