Preparing for a Single TB and HIV Concept Note: What is New in the Global Fund and

Opportunities?

Lisa J. Nelson, MD MPH MSc

Representing the Interagency TB and HIV Working Group (Global Fund, PEPFAR, Stop TB Partnership, UNAIDS, WHO)

Outline

1. Rationale for the decision

2. Investing strategically in HIV and TB: building systems and creating

efficiencies

3. How to get to joint programming for HIV and TB?

4. What is the role of partners in providing support for Global Fund?

5. Next steps

3

How is the New Funding Model Different?

• Passive portfolio management

• More active portfolio management

• Low predictability of success and

available funds

• Global Fund Country Teams involved

• Cumbersome process to grant signing

• Disbursement-ready grants

• Global Fund Rounds

• Hands-off Country Team

• Timelines determined by each

country

• High predictability: timing, success,

funds

Previous Model

NEW Funding Model

• In 2012, 1.1 million (13%) of 8.6 million people who developed TB worldwide were HIV-positive

• In the same year, 1.3 million died from TB, of which 320, 000 were people living with HIV

• The highest rates of TB and HIV co-infection are in Africa, where 43 percent of TB patients had a positive HIV test result in 2012

Joint TB and HIV Applications

4

Countries with high co-infection rates of TB and HIV shall submit a single concept note that presents integrated and joint programming for the two diseases

(GF/SIIC09/DP6)

Recognizing the importance of core TB-HIV collaboration services, the Board’s Strategy, Investment and Impact Committee decided that:

Rationale for the Decision

• Slow uptake of evidence-based global policies

• Logistical and administrative challenges to the introduction of updates to existing practices and systems

• Non-harmonized, non-standardized and duplicative TB and HIV monitoring and evaluation systems

• Poor utilization of Global Fund resources for TB/HIV collaborative activities despite advocacy since 2004

• GF cumulative expenditures (2002-2011) for TB/HIV represented only 4% of TB grants and 1% of HIV grants

• Opportunity to enhance impact with submission of a joint concept note

6

GF/SIIC09/DP6 Preparing internally for next steps

• Meeting 21 October 2013

High TB/HIV burden countries Estimated incidence of TB/HIV, 2012 (WHO)

High TB/HIV burden countries Estimated incidence of TB/HIV, 2012 (WHO)

South Africa 330,000 Indonesia 7,500 India 130,000 China 7,300 Mozambique 83,000 Namibia 7,300 Zimbabwe 55,000 Angola 5,500 Nigeria 46,000 Central African Republic 5,300 Kenya 45,000 Botswana 5,100 Uganda 35,000 Ukraine 4,800 Zambia 35,000 Haiti 4,300 United Republic of Tanzania 32,000 Sudan 4,300 Ethiopia 23,000 Chad 4,100 Cameroon 19,000 Sierra Leone 3,900 Myanmar 19,000 Congo 3,600 Brazil 16,000 Rwanda 2,900 Democratic Republic of the Congo 16,000 Ghana 2,800 Malawi 16,000 Cambodia 2,700 Swaziland 13,000 Burundi 2,500 Thailand 12,000 Burkina Faso 1,600 Lesotho 9,900 Mali 1,200 Russian Federation 9,300 Togo 1,200 Viet Nam 9,300 Djibouti 540 Côte d'Ivoire 8,000

41 Countries with High TB and HIV Co-Infection

Communication of the Decision

• November 2013: Letter from the Chair of the Global Fund Board - to the ministers of health of countries to which this decision applies

• December 2013: FAQs on the Global Fund website + dissemination by WHO, UNAIDS, Stop TB Partnership and PEPFAR to all in-country partners to ensure coordination and understanding

• Beginning of 2014: Tools and guidelines for the new funding model taking into consideration the Board decision on the single TB and HIV concept note: http://www.theglobalfund.org/en/about/grantmanagement/fundingmodel/

• For any outstanding questions: e-mail to HIV_TB@theglobalfund.org

Framework for New Joint Concept Notes

Tuberculosis (TB)

HIV

TB/HIV Collaborative

Activities

Cross-cutting opportunities to strengthen health systems

Investing strategically in HIV and TB: building systems and creating efficiencies

Critical Areas for the Joint TB and HIV Programming

• Harmonisation of policy and programme management

– Conducive policy and programme environment

– Effective programme management for execution of policies and joint plans

• Alignment of critical components of the health system

– Health information system

– Procurement and supply chain management

– Health workforce

– Financing

– Laboratory systems

• Integrated TB and HIV service delivery

• Community systems strengthening

• Human rights, gender equity and key populations engagement

How to get to joint programming for HIV and TB?

Levels of Joint Programming

Global

National

Subnational/District

Facility

2nd GAC

The Single CN in the New Funding Model

Concept Note (full expression of

demand) 2-3 months

Grant Making 1.5-3 months

Board

TRP

GAC

• Joint program reviews where possible, but at least joint participation

• No requirement for joint NSPs

• Joint Country Dialogue

Ongoing Country Dialogue

National Strategic Plan

determined by country

Grant Implementation

3 years

• CCM can continue to choose the implementers that are most appropriate given the country context

Single HIV and TB Concept Note

TB s

pe

cifi

c H

IV s

pe

ific

• Assess the level of, and trends in, TB disease burden (incidence, prevalence, mortality).

• Assess whether trends in TB disease burden are plausibly related to programmatic efforts or other factors

• Assess the level of, and trends in, HIV(incidence, prevalence, mortality).

• Identify key populations and determinants

• Assess impact of programmatic efforts

• Assessment on the need, advantage and feasibility of conducting Joint TB and HIV programs review including timing, logistics and epidemiology of the diseases through consultation with CCMs and FPM

• If joint review is decided, identify priority and specific areas to be covered for the joint review for TB and HIV programs through national dialogue and epi-assessment

• Develop TOR for the Joint Review and conduct the review

While the previous three steps can depend on need, feasibility and epidemiology of the diseases in the country, provision of coordinated TA for TB and HIV under the overall guidance of the CCMs is essential for the identified countries. Specific expertise for prioritized TB (e.g. MDR TB, PPM, TB case finding) and HIV (e.g. ART, VMMC, PMTCT) areas will be sought in a coordinated manner.

Based on need, feasibility and epidemiology of the diseases countries with no NSP are encouraged to develop or update their TB and HIV or a joint TB and HIV NSPs with due consideration of the synergies and priorities of the HIV and TB programming, the scaling up of collaborative TB/HIV activities and the needs of the country.

Cross cutting for both TB and HIV will be coordinated and considered together for both TB and HIV. This include the following examples: information system, laboratory services, procurement and supply, community engagement, human resources, infrastructure, service delivery models and mechanisms, investment of existing GF funds and human rights. Based on need and the priority of the country, flexibility need to be sought to include malaria and other health programmes while addressing cross cutting issues.

Continuous joint country dialogue of TB and HIV stakeholders through CCM and other national fora

Joint Epi-assessment Preliminary (The basis)

Joint TB and HIV programs review

Joint TA for concept note preparation

One concept note developed

NSP

Update or develop a new NSP

Cro

ss c

utt

ing

• Aiming for a country-driven process that recognizes different

country contexts

• Existing timelines for HIV and TB processes present a challenge, but can be harmonized over time

• What components can be integrated, what coordinated?

Additional Considerations

Objectives of the Joint HIV, TB and PMTCT Review 2013, South Africa

• Review progress in implementation of national health sector targets

• Review level of programmatic and service integration, decentralization and synergies

• Assess quality and effectiveness of services

• Assess capacity and challenges in supply chain, M and E, laboratory and staffing

First ever Joint National Review of HIV, TB and PMTCT

What is the Role of Partners in Providing Support for Joint Concept Notes?

• Coordination and alignment of technical support

• Already begun through the Interagency TB and HIV Working Group (WHO HIV and TB, Stop TB, UNAIDS, PEPFAR and Global Fund)

• Development and dissemination of materials

• Frequently asked questions

• Information Notes and Technical Guidance Notes

• Engagement with countries applying in early 2014 to provide additional support

Estimated Timing for TB/HIV CN

Estimated Timing for TB/HIV CN

These are high TB/HIV burden countries without timelines

Next Steps

• Workshop for Single Concept Note February 17-19th

• UNAIDS, WHO (TB and HIV), Stop TB Partnership, USG, Global Fund, UNICEF

• Input from this group

• Complete and disseminate guidance to countries and partners

• Coordinate additional trainings and workshops

• Country-by-country mapping

Conclusions

• Single Concept Note provides critical opportunity

• Enhanced impact

• Role of partners will be key

• Country-specific response will differ, but approach will provide a new way of doing business