What happened to PEPFAR's $100M Key Population Investment Fund?

AMSTERDAM — The head of the United States President’s Emergency Plan for AIDS Relief has said government bureaucracy prevented her from giving $100 million directly to in-country groups targeting key populations living with HIV.

The money will now be delivered through U.S. government agencies instead, Ambassador Deborah Birx said.

HIV/AIDS groups have been keen to know the whereabouts of the money behind the Key Population Investment Fund, a five-year funding stream announced in 2016 to support the scale-up of community-based approaches to enhance HIV service provision for key populations and marginalized groups, such as sex workers, drug users, and LGBTQ communities. The fund also included support for evidence gathering and advocacy activities.

Nearly two years after the request for applications was posted with a deadline of October 2016, those who applied now have an answer — after PEPFAR’s Birx admitted she had failed to get the fund off the ground.

However, Birx said the money was still earmarked for key population groups and would be dispersed through PEPFAR’s usual U.S. government agencies. The original plan was to move the KPIF money through a U.S. State Department funding mechanism directly to NGOs, who would then on-grant to “indigenous” organizations, a PEPFAR spokesperson told Devex.

Speaking at a side event during last month’s AIDS 2018 conference in Amsterdam, Birx was interrupted by protestors demanding answers about KPIF.

She told them: “It’s my fault. Because I couldn’t get the money to move the way it needed to move; it was going to take another seven months and I just couldn’t wait.” As a result, “we have put our key population funds through a different mechanism,” she said.

Birx went on to say that U.S. bureaucracy had proved too difficult and time-consuming to circumvent.

“I failed to make it happen despite two years of very aggressive work because I was trying to make a bureaucracy bow to my wishes, [but] I wasn’t willing to keep that going just to win that fight,” she explained.

HIV/AIDS groups say they are worried that going through U.S. agencies will mean less money gets into the hands of local actors best placed to work with key populations.

When it was announced during the 2016 United Nations High-level Meeting on Ending AIDS, KPIF was greeted with enthusiasm for its focus on key populations and its promise to get more money more quickly into the hands of community groups.

This was to be achieved by skipping out PEPFAR’s traditional government agencies — such as the U.S. Agency for International Development and the Centers for Disease Control and Prevention — and instead, the money would go straight to implementing organizations. The prime recipients were asked to bid for the money, then could subgrant to smaller, local key population-led groups. Bidding was open to grant requests of $500,000 to $10 million for up to four years.

HIV experts increasingly agree that delivering more services to key populations will be crucial to controlling the epidemic, which is experiencing a resurgence in some areas and amongst some populations.

There were 1.8 million new HIV infections in 2017, only 100,000 less than in 2010, 47 percent of which affected key populations including men who have sex with men, sex workers, people who inject drugs, and LGBTQ groups, according to UNAIDS. Such groups are less likely to access prevention and treatment services due to stigma, criminalization, and discrimination.

George Ayala, head of MPact Global Action for Gay Men’s Health and Rights, said he was upset by the delays. MPact submitted two proposals to KPIF back in 2016, one of which ended up in the final stages before the process “just stopped,” he said. He is worried that the move to administer the fund through U.S. agencies will mean less money reaches community groups, and that programming could be less effective and more risk-averse. He has written to Birx outlining his concerns.

“I’m worried [that] if the money is moving through the additional channels of U.S. agencies, those agencies won't necessarily do a good job of getting money to community-based groups led by or trusted by key populations,” he said, adding that he feared a lot of money will “stay locked up in large agencies and large NGOs.”

Part of the problem is that these large organizations “don’t have good partnerships on the ground,” and also have high overhead costs which will eat into the funding, Ayala said. He added that many larger groups prefer not to take the risk of granting to smaller community groups, and so “may try to do the work themselves.”

This raises additional problems for Ayala, who said large international bodies are unlikely to have staff with direct experience of the “day-to-day lived experience of key populations,” unlike community-based groups who work closely with them. Larger organizations may also be reluctant to deliver services to key populations including sex workers and LGBTQ groups in places where they are criminalized, and may also be unaware of how to deliver those services in a way that protects the anonymity of the person, he said.

Christine Stegling, executive director of the International HIV/AIDS Alliance — that applied for KPIF funding in 2016 but never got a response — also said she was disappointed to hear the money would not be going directly to local actors.

“Birx wanted to do direct disbursement, so now it’s having to go through the old channels,” she said. Communities need to be told what has happened to the money and how it will be dispersed going forward, Stegling added.

In a statement, a PEPFAR spokesperson confirmed that the $100 million allocated to KPIF “remain to be disbursed,” and that it will now be channeled through PEPFAR government implementing agencies, but will still “primarily support indigenous organizations that are reaching key populations with critical HIV prevention and treatment services in communities.”

The spokesperson also confirmed Birx’s explanation of the delay: “We initially tried to move the KPIF resources in a new way, but that approach has been too slow and would still take significant additional time. We want to ensure our financial resources can work as quickly as possible for key populations in need of HIV prevention and treatment services, so we are rapidly shifting to our traditional ways of moving money.”

In terms of how HIV groups can access the money, the spokesperson said PEPFAR is working with the government implementing agencies “to determine the most effective and efficient procurement processes to ensure the resources previously committed to the KPIF are put to use as quickly as possible for people in need.”