Global Fund grants in Guinea are facing numerous challenges. On 23 February, the Global Fund Board approved an HIV grant, GIN-H-MOH, in the amount of $33.6 million, with the Ministry of Public Health (MOPH) as a new principal recipient (PR). The Board was acting on a recommendation from the Technical Review Panel (TRP) and the Grant Approvals Committee (GAC). Last December, the Board approved a TB/HIV grant for Guinea, GIN-C-PLAN, in the amount of $14.6 million. The PR for that grant, Plan International, implements the prevention component of Guinea’s HIV program, primarily focused on key populations. (Plan International is also a new PR. It takes over from Population Services International, which, according to the Secretariat, is closing its operations in Guinea.) The MOPH takes over from the Comité National de Lutte Contre le Sida (CNLS). Both the TRP (when it reviewed Guinea’s HIV funding request in 2017) and the Office of the Inspector General (in an audit of Global Fund grants to Guinea in 2017) had identified weaknesses in the capacity of the CNLS. Guinea is classified a challenging operating environment due to ongoing political and civil unrest. Grants to Guinea are administered under the Fund’s Additional Safeguard Policy. Guinea has a national HIV prevalence of 1.7%. The prevalence among sex workers is 14.2%; among men who have sex with men, 11.4%; and among miners, 5.6%. Treatment coverage is low, at 27% vs. a 2016 target of 43%. The GAC said that scale-up of treatment is hampered by the slow opening of new sites, delayed trainings for health care personnel, weak laboratory capacity and inadequate supply chain management. In addition, the GAC said, there are frequent stock outs at the peripheral level. The Global Fund is the primary external funder of Guinea’s HIV response, apart from technical assistance provided by partners. The Global Fund is now funding 80% of the national HIV cohort, the GAC noted, “thereby further increasing the risks associated with commoditizing the Guinea HIV grant.” The GAC has expressed concern before about grants where a very large proportion of the funding is devoted to procuring essential health products, leaving little room for other programs. (See GFO article.) Although it recognized the urgency of investments to guarantee coverage of the current cohort, the GAC stressed the importance of ensuring linkages between (a) the HIV testing strategies and treatment targets and (b) the level of support that the grant can sustain, given the ambitious targets proposed by Guinea. In addition, the GAC highlighted the need for a technically sound testing policy to improve the efficiency and effectiveness of HIV testing. Despite progress made on the treatment cascade and a retention rate of 79%, the GAC said, more focus is needed to reach coverage targets, and improvements are required in the following areas: linkages to treatment after testing; programmatic quality; and interventions for key populations. Considering the challenges Guinea faces in terms of reaching some key populations groups, the GAC said, there is a need to develop comprehensive strategies across the prevention and treatment programs, and to ensure synergies with the grant being managed by Plan International. The GAC noted the particular challenges concerning the supply chain in Guinea, which were exacerbated by a fire at the national medical warehouse in June 2017. To mitigate the risks linked with the supply chain, the Secretariat has put in place several measures, including contracting Catholic Relief Services (CRS) to act as a permanent service provider for supply chain support to the Ministry of Health. CRS will provide support in the following areas: quantification, distribution, order tracking, and integrating HIV into the national supply chain. Finally, the GAC stressed the importance of valid and reliable data for an accurate understanding of Guinea’s HIV epidemic. TRP comments When it reviewed Guinea’s program continuation HIV funding request, the TRP said Guinea has made some progress, “albeit slowly,” in implementing its current HIV grant. However, the TRP said that most of the targets in the funding request were “set too low to have a substantial impact on the epidemic.” The TRP also said that more effort is required in programming for adolescent girls and young women (AGYW). The TRP recommended that Guinea:

• provide a stronger description of the women and girls who are vulnerable, including the risks of gender-based violence and informal sex work;
• address gender-based violence through expansion of comprehensive post-rape services and evidenced-based interventions, including economic support;
• strengthen the linkages with reproductive, maternal, neonatal and child health to improve the performance of the prevention of mother-to-child transmission program; and
• ensure access to comprehensive reproductive health care for sex workers.

  Grant documents state that the AGYW issues were satisfactorily addressed during grant-making, but they don’t explain how they were addressed, except to say that follow-up on these issues is part of the work on the development of Guinea’s national strategic plan for 2018–2022. Co-financing For the 2017–2019 allocation period, the Government of Guinea has committed to investing $18.7 million in HIV, representing an additional investment of $8.7 million compared to the 2014–2016 allocation period. This more than meets Guinea’s co-financing requirement. The government will maintain its investments in human resources and operational costs from the 2014–2016 allocation period and will also contribute to health products (ARVs, drugs for opportunistic infections, reagents and consumables). However, given the Secretariat’s limited visibility of orders placed for HIV commodities by the government, as well as the shortfall in the government’s purchase of health products during the 2014–2016 allocation period, the grant agreement includes a requirement to provide a bi-annual detailed list of health products ordered by the government. This will enable national quantification exercises for HIV and TB with full visibility of the national and Global Fund pipeline. In addition, to ensure ongoing monitoring of national contributions, annual reporting from the Ministry of Finance will be required. Program review A joint HIV program review is planned with technical partners for the second quarter of 2018; the GAC said that this will pave the way for a reprogramming in 2019. The Secretariat is also engaging with national entities and technical partners to support the finalization of the 2018–2020 National HIV Strategic Plan which was not completed as anticipated in 2017. Recoveries Guinea has owed the Global Fund $112,354 in recoveries since September 2015. According to the GAC, after considerable efforts were made to recover the funds, unuccessfully, in October 2017 the Global Fund applied its 2:1 policy and deducted twice the amount of the recoveries from Guinea’s 2017–2019 allocation. The funds were taken out of the budget for the MOH HIV grant. Some of the information for this article was taken from Board Document GF-B38-ER08 (“Electronic Report to the Board: Report of the Secretariat’s Grant Approvals Committee”), undated. The Guinea HIV grant was the only grant included in the report.    

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