Fund medicines or fund the programmes that support uptake and adherence? That's the choice countries are now facing amid Global Fund shortfalls. With money tight, countries are slashing civil society-led HIV and TB programmes - treatment supporters, community-based volunteers, support for people living with HIV - to safeguard essential services, according to preliminary research being conducted by the Open Society Foundations.
In November 2011, the Global Fund to Fight AIDS, TB and Malaria faced US$2.2 billion in unpaid donor pledges and cancelled its Round 11 of funding. This was the most dramatic manifestation of years of broken donor promises.
Two years earlier, Global Fund donors reneged on almost 15 percent of pledges - a figure that rose to almost a quarter of donor pledges in 2010, according to former Global Fund Executive Director, Michel Kazatchkine's November 2011 report to the board.
To ascertain the impact on civil society of these Global Fund shortfalls, OSF undertook research in three countries that had planned to apply for Round 11 funding - Swaziland, Malawi and Zimbabwe.
Through interviews with nearly 45 representatives from civil society, Global Fund Country Coordinating Mechanisms (CCMs), HIV and TB programmes, and UN agencies, OSF found that these countries are facing funding gaps for essential services such as HIV and TB testing and treatment, prevention of mother-to-child transmission services (PMTCT), and support for orphaned and vulnerable children (OVC).
The research found that to free up funding for these initiatives, all three countries are cutting the kinds of complementary, civil society-led activities identified as 'critical enablers' in the UNAIDS Strategic Framework.
Swaziland has now halted HIV prevention programmes with the exception of PMTCT and medical male circumcision and may re-programme phase II of its current Global Fund money to shift more money towards buffer ARV stocks, according to Vusi Nxumalo, CCM member and Vice Chairperson of the Swaziland National Network of People Living with HIV and AIDS.
Swaziland's Round 11 application - like that of Namibia - would also have been the first to include HIV prevention programming aimed at criminalised, most-at-risk populations, such as sex workers and men-who-have-sex-with-men. In addition, the country would have addressed the needs of its small population of injecting drug users.
Malawi and Zimbabwe have already cut CSO activities under their Phase II renewals to shift money towards medicines, HIV testing kits and PMTCT.
For example, Zimbabwe's recently approved Round 8, Phase II renewal has slashed funding for behaviour change communication in communities and schools by 54 percent; institutional capacity building and strengthening of PLWH networks by more than a quarter (27 percent); and OVC support by almost a fifth (17%) - all without consulting CSO implementers.
"The removal of behaviour change communication is not justified," said Joyce Siveregi, deputy director for programmes at the Zimbabwe AIDS Network.
It's not the first time that countries have had to cut CSO programming to preserve drug stocks and diagnostics.
In 2009, the Global Fund mandated a 10 percent 'efficiency gain' in Round 8. Unpublished OSF research found that during grant negotiations, most countries felt resources for commodities such as medicines, lab equipment and infrastructure could not be reduced. Instead, gains were achieved by decreasing resources devoted to programmatic components primarily implemented by CSOs, such as information, education, and communication materials and campaigns, prevention activities, and outreach services targeting marginalised and vulnerable groups
Under OSF's current research, about 80 percent of CSOs said organisational funding had declined in the past two years, with several, longstanding organisations citing funding cuts of up to 30 percent.
To cope, CSOs have scaled back or cut both staff and the kinds of programmes they were forced to cut in 2009 - most prominently, community systems strengthening, human rights and/or community mobilisation programming.
Ironically, respondents reported that community-based organisations, including those comprised of PLWH, were among the types of CSOs most affected.
"These are not organisations that are going to be supported under the Transitional Funding Mechanism," Vusi Nxumalo told OSF. "We are losing the community structures that we've built up. If there comes a time when there is more money for HIV, we're going to have to go back into communities and build these structure all over again."
Now that the Global Fund has announced that it has US$1.6 billion available to begin investing in new programmes, it needs to prioritize investments in the communities it was set up to serve.