In an exchange of letters that spanned more than seven months, the Global Fund at first rejected a plea for help from the Venezuelan Network of Positive People (RVG+), but then may have left the door open to providing some assistance via other agencies. This is a story that is still unfolding.

According to the Global Fund, Venezuela is currently not eligible for funding under the Fund’s Eligibility Policy.

On 6 June 2016, the Board of the Venezuelan Network of Positive People (RVG+) wrote to the Board and the Executive Director of the Global Fund asking the Fund to make an exception to its rules in order to provide urgent humanitarian aid for HIV and TB.

The letter said that although Venezuela is classified as a high-income country, this classification does not reflect the reality on the ground. The letter described the deteriorating medical system in Venezuela, including ongoing treatment interruptions and stock-outs of antiretrovirals (ARVs). It also referred to a lack of access to essential medicines and medical supplies, as well as dangerously contaminated surgery rooms, ill-equipped laboratories, water and electricity disruptions, long lines at supermarkets and widespread food insecurity.

“Several thousand people with HIV are now without antiretroviral treatment,” the letter stated. “We would like to ask you to … provide urgent humanitarian aid for HIV-AIDS and TB, literally we are not only suffering hungry, but we are also dying because our health system is totally collapsed.”

On 18 January 2017, more than seven months later, Norbert Hauser, Chair of the Board, and Mark Dybul, Executive Director, responded that “the current policy framework does not allow the Global Fund to provide funding to Venezuela.”

“As an agency relying itself on donations from multiple stakeholders,” the letter said, “the Global Fund is not in a position to grant any exceptions from its rules.”

On 31 January, in response to the letter from the Fund, RVG+ and a number of civil society organizations and individuals in Venezuela, released a public letter in which they said, “After 7 months of waiting for a response, we consider the letter sent to Venezuelans with HIV by the Council President and the Executive Director of the Global Fund, Norbert Hauser and Mark Dybul, to be unacceptable, unjust and without humanity.”

The letter said that in the past the Global Fund demonstrated flexibility and offered special assistance to countries in critical situations. The letter cited the case of the Russian Federation where “Russian civil society received special grants, which allowed them to develop projects aimed at reducing harm and preventing new HIV infections among injecting drug users.”

RVG+ and the CSOs and individuals who signed the public letter “urgently requested” that the Fund reconsider its response. They also called for the resignations of Mr Hauser and Dr Dybul because “they lack the sensitivity and leadership to even try to seek some kind of response to a situation of humanitarian, health and food crisis the population of Venezuela is suffering.”

Reaction from other organizations

Reaction to Global Fund’s letter was swift. The Global Network of People Living with HIV (GNP+) expressed grave concern and profound disappointment with the Global Fund’s decision. ICASO said that “the deteriorating situation inside Venezuela demands international action” and that the response from the Global Fund “is not acceptable.” The AIDS Healthcare Foundation (AHF) called on the Fund to revisit its “all-too-bureaucratic rejection for assistance.”

People were urged to sign a petition calling on the Global Fund “to urgently approve exceptional funding for Venezuela, through some of its technical partners … as well as through civil society organizations.”

Feliciano Reyna Ganteaume, whose Caracas-based non-profit Acción Solidaria provides ARVs, said in the magazine Science that the situation “is much worse than one can describe.” When the government does take action, he said, drug orders are placed late and not paid for on time, causing interruptions that have lasted more than three months. “There is not even one month without our receiving complaints of lack of one or more ARVs from one or more Venezuelan states.” Reagents for the tests needed to monitor people on treatment also are in short supply.

Ganteaume said that in 2015 an estimated 110,000 people were living with HIV in Venezuela, of which at least 63,000 had started ARV treatment.

Second letter from the Fund

On 2 February, the Global Fund sent a second letter “clarifying” its previous response. Mr Hauser and Dr Dybul said that the Fund “has been following the developments and remains very concerned about the effect of the current crisis on the people of Venezuela, the public health system, and on HIV, TB, and malaria.” They said that the Fund is working closely with the Pan American Health Organization (PAHO) and UNAIDS as the agencies best placed to lead the response to this crisis. “The Global Fund has never operated a country grant in Venezuela and therefore must work behind these lead organizations, particularly because the government has not requested health assistance.” [Emphasis added]

The letter stated that the Global Fund would consider any requests for assistance “from partners who are leading in the response” for:

• access to competitive pricing for emergency procurement of commodities which could support a short-term response with regards to essential commodities for HIV, TB and malaria;
• longer-term support through a multi-country malaria grant to provide support to address the regional consequences of Venezuela’s increasing malaria rates; and
• other needs that the Global Fund can provide within its mandate and resources.

“We will continue to closely monitor the situation and work with the lead agencies,” the letter said. “We stand ready to consider any specific requests for assistance.”

More reaction

On 10 February, in an open letter to the Board of the Global Fund, AHF called for the immediate resignation of Dr Dybul. “The Global Fund showed a wanton lack of care and concern by taking seven months to respond to a desperate plea for help from RVG+,” AHF said. “It appears the leadership of the Global Fund is out of touch with realities on the ground in crisis hotspots like Venezuela, where people are dying or at risk of dying every day without antiretroviral drugs, HIV test kits and diagnostics and treatment for tuberculosis.”

AHF pointed out that the Board has made exceptions to its Eligibility Policy before. “In 2009, the Board approved emergency funding for Russia even though it acknowledged that under the current income eligibility policies of the Global Fund, the Russian Federation is not eligible for … HIV/AIDS funding.” (Editor’s note: This refers to a decision by the Board to extend a Round 3 grant for which the Open Health Institute was the principal recipient.)

AHF criticized the Global Fund for saying that Venezuela did not meet the eligibility criteria “based on its former status as a high-income country.” AHF said that World Bank historical data from 1998 to the present show that Venezuela was classified as high-income only once, in 2014. “In all other years, it was classified as an upper-middle-income country, which would make it eligible for funding.”

[Editor’s Note: In their first letter to RVG+, Mr Hauser and Dr Dybul did cite Venezuela’s high-income status as a reason for the country not being eligible for funding. However, they did not do so in their second letter. Instead, they said that “the Global Fund’s eligibility policy … requires countries to be eligible for at least two consecutive determinations/years in order to be eligible to receive an allocation of funding and that to determine income classification the Global Fund uses a three-year average of GNI per capita.” In addition, it should be noted that income level is not the only criterion; the level of disease burden is also a factor.]

Questions remain

There will almost certainly be more developments in this story. Here are some questions that Aidspan has about what has transpired so far, along with what information we have been able to obtain:

• Why did it take more than seven months for the Global Fund to respond to the initial request for assistance from RVG+? This remains a mystery.
• Were all Board members consulted on the response?  Apparently not. Aidspan understands from sources in the Latin America and Caribbean (LAC) region that the E.D. and Chair of the Board wrote to the RVG+ without a full discussion of the board.
• Where is the Government of Venezuela in all this? Aidspan understands that in November 2016, RVG+ participated in a meeting with two government officials, including one from the National AIDS Program in the Ministry of Health. The government officials were invited to ask the Global Fund for assistance to deal with the crisis. The officials declined, saying that the government had sufficient resources to respond to HIV. One person told Aidspan that now that the Global Fund has indicated a willingness to consider providing some assistance via PAHO and UNAIDS, “maybe it would be better if the government just stayed out of the way.”
• How much assistance does Venezuela need from the international community? In its letters to the Global Fund, RVG+ did not provide a figure. Aidspan understands from a source in LAC that by November 2016, it was estimated that $20 million was needed just for ARVs and HIV testing. This amount does not include medicines for opportunistic infections, prevention initiatives and other aspects of the fight against HIV, including human rights.

Aidspan Comment:

It is hard to understand why the Global Fund is reluctant to provide assistance. It is clear that the Fund made a special effort (more than once) to get money to Russian NGOs. Why can’t it do the same for Venezuela?

The Global Fund’s decision to work through PAHO and UNAIDS has not shown any results as yet. Presumably, both agencies believe they have to work through the Government of Venezuela, but there is no indication of any movement in this direction. Is having the government onside the key to resolving this crisis? Maybe. But it seems to us that in the case of the Russian Federation, the Fund worked around the government, not through it.