This is a POLITICO case study, a look at what works — and what doesn’t — in the fight against HIV. The article is part of Telescope: The New AIDS Epidemic, a deep-dive investigation into the modern face of a disease that transformed the world.
THE BIG PROBLEM
Resources for tackling HIV around the world are finite and getting smaller in recent years as AIDS falls down the list of priorities for humanitarian aid.
THE BIG IDEA
The Global Fund to Fight AIDS, Tuberculosis and Malaria launched in 2002 to get anti-disease programs off the ground until national governments are ready to take over.
In poor and lower-middle income countries, where the HIV burden is often more severe, that may never happen. But in upper-middle income countries like Bulgaria, the subject of this case study, the Global Fund’s assistance is meant to be “catalytic.” When infection rates and economic prospects improve — based on a series of benchmarks — countries are weaned off the Global Fund cash and expected to keep carrying on on their own.
WHY IT MATTERS
Whether countries like Bulgaria can successfully transition from Global Fund support has worldwide implications. Because HIV/AIDS disproportionately affects communities on the social margins — gay men, people who use drugs, migrants, sex workers — governments don’t always have much political incentive to continue to invest. Other countries have seen progress slip away after losing access to the Fund. Complicating matters, the Global Fund also assesses a country’s political conditions in determining its eligibility for funds.
Over the past 15 years, several Balkan and ex-Soviet states have graduated from deep-pocketed, Geneva-led programs, to domestically-funded and run HIV programs. Donors have to focus on countries with the fewest resources and the greatest number of cases. Compared to Saharan Africa, where hundreds of thousands of new infections occur every year, upper-middle income countries in Central Europe see just hundreds of new cases annually.
But the transition from international aid has often proven rocky. Serbia moved off Global Fund aid in 2014. But the drop-off in services was so severe that hard-fought gains were lost, and HIV cases crept up again. By 2018 Belgrade was right back on Global Fund assistance.
Some countries have managed the transition successfully. In Estonia the downshift from international aid to local government funding went smoothly, with few disruptions to service when Fund support ended in 2007.
HOW THEY DID IT
Bulgaria received nearly $50 million in total from the Global Fund between 2004 and 2017. In 2014, the organization deemed Bulgaria ineligible for future rounds of funding — even though its HIV burden was still defined as “high,” due to the heavy toll on vulnerable groups.
Fifty million wasn’t so much relative to the country’s overall health budget, noted Matthew MacGregor, the Global Fund’s senior manager for sustainability and transition. And with just 3.7 new diagnoses per 100,000 inhabitants in 2019, incidence of HIV in Bulgaria is still well below the EU average of 5.4 per 100,000.
However, some of Bulgaria’s HIV trends are not encouraging. Diagnoses among men who have sex with men, for example have continued to rise sharply since 2008, when there were just 20 new cases. In 2019, there were six times as many, 122.
When it comes to funding from the Global Fund, numbers like that matter. HIV treatment is covered by the government in Bulgaria, and testing is available in state-run health centers. But programs that seek out those vulnerable groups are run by NGOs.
Global Fund aid helped NGOs build up those prevention services, like needle exchange programs, outreach to the LGBT community for rapid testing at places like nightclubs and counseling to help HIV positive people stick to treatments, a key to ending transmission.
HOW IT WENT
After Fund aid ended, the Bulgarian government agreed to hire the NGOs to keep providing those and other services. Though it couldn’t match Global Fund budgets, the health ministry offered contracts through its public contracting system with significant cash behind them.
The contracting system — not the dropoff in cash — turned out to be the stumbling block to a smooth transition.
As grants neared expiration, experts flagged that Bulgaria’s public tender system was “inappropriate” for social services, as one 2015 report put it. The government offered training sessions to NGOs to help them apply for the tenders, according to a written statement from the health ministry, which declined an interview request.
MacGregor said the Global Fund tried to analyze potential problems and even extended the grant well beyond its official expiration date of December 31, 2015. But when the last of the funding dried up in mid-2017, it was up to the Bulgarian government and NGOs to manage on their own.
IN THEIR VOICES
The Global Fund’s Matthew MacGregor on the fundamental importance of political will at the national level:
The civil society sector says its outreach and harm reduction work has been decimated by the Global Fund’s departure in mid-2017. Services remain patchy at best.
NGOs detailed a litany of problems with the contracting system in a report published last year. Among them: Bidders have to show they had cash available up-front to set up the service and buy supplies. NGOs couldn’t meet these demands, and many ceased operations.
Initiative for Health, the country’s first harm-reduction NGO for people who use drugs, was one of the casualties. It closed shop last year, after 22 years of offering clean syringes and HIV tests via delivery van.
IN THEIR VOICES
Anna Lyubenova, a longtime psychologist with the now-defunct Initiative for Health, on the struggle to abandon vulnerable clients:
ZOOMING IN: CHECKPOINT SOFIA
A single, non-profit clinic has been responsible for some 20 to 25 percent of the nation’s HIV diagnoses over the past few years, performing some 6,000 tests annually. That’s according to Elena Birindjieva head of the Bulgarian NGO Health Without Borders, which operates the clinic, Checkpoint Sofia. Now, its future is uncertain.
With a staff of 16 to 20, including field workers spread through the MSM community, the Global Fund-backed clinic provided a full range of free services, from HIV testing and case management, to other STI screenings. It could operate comfortably with an annual budget of about €60,000.
Now, that team is down to four including Birindjieva, a nurse by training. there’s no money for the field workers, so their efforts are purely voluntary. Donations from the pharmaceutical company Gilead (the advertiser presenting Telescope: The New AIDS Epidemic) helped the clinic stay afloat for much of the past two years. But for 2021, there’s no operating budget.
Checkpoint Sofia has started charging for some STI tests and others services — though HIV testing and case management are still free. As other services shut down, said Birindjieva, some people are traveling up to 400 km to be tested in the clinic in the capital.
Fortunately, about 80 percent of their clients have been pretty understanding about the new costs. But Birindjieva feels abandoned by everyone else: the Global Fund, Bulgaria’s constantly reshuffling government, municipalities that refuse to step in.
IN THEIR VOICES
Elena Birindjieva on her frustration with the situation in Bulgaria compared to other countries that have transitioned off Global Fund assistance.
ON-THE-GROUND RESULTS
Available data offer mixed signals on how the transition has affected Bulgaria’s fight against HIV. While treatment is a bright spot, there are worrying signs that more cases are going undetected.
Treatment: While estimates vary, Bulgaria is clearly finding its footing on providing treatment with antiretrovirals, a direct purview of the government. (The health ministry contends UNAIDS overestimates the number of people living with HIV in Bulgaria and other low-burden countries, and that 98 percent of the 1,817 confirmed HIV cases in the country are on treatment.)
Testing: In contrast, NGOs argue that the total undiagnosed population may be underestimated, given severe stigma against LGBT people.
The health ministry provided data showing testing has increased modestly since the Global Fund left. Some 832,881 tests were performed during the last 2.5 years of the grant, while 841,655 were logged between mid-2017 to the end of 2019.
Civil society groups argue it’s still too early to tell what the long-term effects might be as their targeted prevention and testing for the most at-risk people ends. Tests at Checkpoint Sofia, for example, are not included in the government’s post-Global Fund tally, Birindjieva said.
Bulgaria is moving in the wrong direction on one key measure of its testing strategy: late diagnosis. Around half of all new HIV cases are discovered years after infection. Bulgaria has typically performed about in line with the EU average. In 2017, for example, when Global Fund-backed programs operated for half the year, 47.8 percent of diagnoses were late, while the EU average was 48.6 percent.
In 2018, however, 55.9 percent of diagnoses in Bulgaria were late. And in 2019, that figure went up to 62 percent.
Bulgaria also saw a spike in full-blown AIDS cases, a sign of either treatment failure or severely late diagnosis. AIDS incidence has declined over the past decade around the EU, except in Bulgaria and Hungary, according to the European Centre for Disease Prevention and Control. Between 2018 and 2019, AIDS cases in Bulgaria spiked by more than 50 percent.
In a statement, the health ministry said late diagnoses and AIDS cases were again on the downswing in 2020, according to preliminary data. (Due to the coronavirus pandemic, HIV services faced disruption worldwide.)
THE TAKEAWAY
International priorities: Global Fund officials acknowledge that Bulgaria went through its process before the organization adopted a formal set of transition policies in 2018. Learning from earlier setbacks, the Global Fund now offers specific money earmarked for the transition, and there’s more emphasis on helping NGOs stay afloat and find alternative benefactors if the government doesn’t step up.
In the end, Bulgaria’s problems pale in comparison to other Global Fund recipients, even in the neighborhood. Some growing pains may be unavoidable and unique to each country’s individual situation. The Global Fund reconsidered Bulgaria’s situation ahead of its 2020 round of grant decisions, but opted not to offer new money. Wealthier countries need to be able to manage on their own.
IN THEIR VOICES
MacGregor on the Global Fund’s need to prioritize:
The Brussels angle: The government says it wants to adjust the contracting rules to help the NGOs, but contends the EU’s 2014 public procurement directive won’t allow it. The health ministry said it would back an EU-level initiative to exempt social services from the European directive, and it’s working with NGOs to figure out how to tweak the tenders. (The European Commission, for its part, said it hasn’t received any complaints.)
Political powerlessness: For NGOs, the problems just confirm what their worst fears: the marginalized people most vulnerable to HIV just aren’t a political priority.
IN THEIR VOICES
Lyubenova on the political and practical consequences of stigma:
BIG QUESTION
Will the Bulgarian state find a solution in time to maintain their momentum?
Or will the fight against HIV in Bulgaria stay in the current grey zone, not as robust as it once was, but not enough of a crisis to spur more action: a victim of its own success?
Audio production by Cristina Gonzalez.
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