Carla, in her late 40s, is a big-boned woman locked in a man’s body, a sweet-natured figure on the streets of San Salvador, a fact of life which nearly got her killed. If it were not for a program to fight HIV/aids financed by the Geneva-based Global Fund to Fight Aids, Malaria and Tuberculosis, she would have died long ago.  William Dowell reports.

Geneva — It takes courage to be gay in Latin America, and especially in El Salvador where a sizeable portion of the country is controlled by gun-toting street gangs, prone to violence and a concept of masculinity that does not allow for nuance. Being a professional sex worker at night, didn’t help. Carla’s determination against all odds to be a woman no matter what the cost landed her in the hospital after being shot nine times by an angry male client. Released from the hospital, she was shot again.

In 2001, she was thrown in jail and tested for HIV/AIDS thanks to a new program made possible by the Global Fund. The test, and a follow up test were both positive. “I didn’t want to believe it,” Carla recalls. “I didn’t know what to do.” Her C4-cell was down to one, and she nearly died.

As it turned out, prison saved her life by detecting the disease and making anti-retroviral treatment available. Today, she is a fully functional person and a force in the community. “I am used to taking the pills on time now,” Carla says. “It is part of my life. I don’t even need an alarm clock. The pills would not have been available, and Carla would probably be dead by now, if it had not been for financing the Global Fund made available to El Salvador’s Ministry of Health.

The rate of HIV/AIDS infection is relatively low in El Salvador when one looks at the entire population, but in certain groups, it is very high. One of these groups is men-having-sex with men, including transvestites like Carla. Another hot spot is the overcrowded prison system. The Ministry of Health was anxious to stop the spread of HIV/AIDS in these hot spots before it spread to the general population. It needed outside financing to do it, and the Global Fund made that possible.

The Global Fund, which is loosely tied to the UN system, is one of the most promising new actors on the development scene, and it is revolutionizing the way future projects across the board are likely to be financed. The idea grew out of discussions from a diverse group that included the Earth Institute’s Jeffrey Sachs, former UN Secretary General Kofi Annan, Bill Gates and the Gates Foundation, Bob Geldorf and a number of others.

The original focus was on HIV/AIDS, but it has now expanded to include malaria and tuberculosis. Malaria may be less dramatic than aids, but it is also wider spread and in many regions, especially parts of Africa, it has a greater negative impact on development. Tuberculosis, once virtually eliminated as a death sentence is coming back in the form of drug resistant strains, especially in cases where resistance has already been diminished by HIV/AIDS.

Although the Gates Foundation was a prominent early funder, most of the funding is now coming from governments. A sizable portion is provided by the US, but the European Union also makes a significant contribution along with other donors. It is currently aiming at establishing a central fund of $20 billion to invest in worldwide health. What makes the fund unique is the concept of turning development into an investment rather than simply handing over cash that may be siphoned off through corruption.

The Fund has no budget for its development programs. Instead it serves as a pool of money which is distributed as project proposals come in. Enough start-up capital is provided to get a project started, but before further funding is made available, the project must achieve clearly identified benchmarks. If that doesn’t happen, the funding is suspended. The benchmarks are verified by external auditors.

The Fund’s communications director in Geneva, John Leyden notes that the success rate is around 85% to 95%, which is why more and more donors are shifting their contributions to the Fund model. The Global Fund is now providing around half of the funding for HIV/AIDS prevention and treatment in the world. About 60% of the investment is in Africa. Central America accounts for only a small portion of the total, but it is important in preventing Latin America from falling into the same pattern that has decimated parts of Africa.

The advantages of the Global Fund’s concept go beyond strict accounting procedures and generous cash grants. One of the conditions of working with the fund is that the country applying for grants has to establish its own central coordinating mechanism—essentially a board of directors which includes both government officials, international organizations like the UN, and the civil society in the form of local NGOs.

The CCM provides a mechanism for the different layers of a developing country’s society to meet on a regular basis and to begin interacting with each other. The Fund’s presence as an international organization, and that of the various UN agencies that may be involved, give the local NGOs a heightened status that makes government officials more likely to listen to them. Finally, the fact that strict standards for releasing funding are set by the Fund itself, frees up other international institutions to become mentors to NGOs and government ministries.

Since these organizations are not responsible for making the decision to grant funding themselves, they become allies helping the host government to formulate its ideas. In El Salvador, the United Nations Development Program, is involved in training and in counseling both local NGOs and the government on how to write effective grant requests, organize project proposals and see to it that projects actually work.

In a sense it is a development version of the classic good cop bad cop approach. The Fund insists on strict standards, while the UNDP advises on how to meet the standards. While some government officials may not be particularly enthusiastic about human rights, they are drawn into considering the issues in order to tap the Fund’s assets.

Why should the Fund occupy itself with the problems of a transvestite like Carla, who in any case was completely outside the system as an illegal sex worker? As both El Salvador’s Ministry of Health and the Fund see it, Carla belongs to an HIV/AIDS hot spot that is keeping the epidemic alive, preventing its eventual eradication and threatening to spread the disease to other sectors of society. As long as people are afraid to admit that they have the disease, it remains hidden and impossible to treat. Repression simply drives the disease underground and makes it impossible to deal with. An estimated 50% of the cases in El Salvador still go unreported.

The most logical solution is a combination of education, free testing and the possibility of affordable treatment with retrovirals. Social change and a respect for sexual identity, even if it appears confused, are key elements in the fight to stop the disease. “I didn’t even know that I was a transsexual,” says Kassie, a friend of Carla’s. “I didn’t know that I was a homosexual. Little by little, I learned about sexual orientations.” The actual relationship between the Global Fund and cases like Carla is indirect but effective. While the government of El Salvador handles 85% of the cost of dealing with aids, it would not have been able to afford the retrovirals, which Carla received in prison, without the financial boost that the fund provided to El Salvador’s Ministry of Health.

In fact, the Fund was able to leverage a relatively small investment into helping El Salvador’s medical authorities towards mastering the tipping point needed to control the disease. Equally important, the Global Fund’s assistance to the United Nations Development Program has financed training to local Salvadoran NGOs on how to organize themselves and how to draft coherent proposals enabling them to generate effective projects on their own.

A strong point in the Global Fund’s philosophy is that the initiative for dealing with the problem comes from the country itself, rather than being imposed from the outside. What the fund does do is to make the financing available for the country to take charge of its own destiny.

Today, Carla works as a coordinator in a local NGO, Rainbow, which represents the rights of transvestites and transsexuals on key issues. At least 23 transvestites were murdered last year. “You can see a lot of hate in these murders,” says William Hernandez, who directs Entre Amigos, a local NGO in San Salvador,“especially against gays and transsexuals.” Rainbow, and other home-grown NGOs including “Orchids of the Sea” and “Stone Flowers,” are effectively involved in behavior modification intended to make their members aware of how to deal with the HIV/AIDS threat and of their own rights under El Salvador’s legal system

It is also working to make a larger public better understand the complexities of being gay and its influence on aids. The problems can be as basic as trying to decide whether you are a man or a woman on a health insurance form. The transsexuals are only a part of  El Salvador’s fight against aids. The problem that is most emotionally difficult to deal with is the orphanages for children whose parents have died from aids. Many of the children have also been infected, and funding injected into the system has offered them a chance at a future. “It has made a huge difference,” says Cecilia Quintamiglia, Director of the Fondacion Esperanza y Allegra, an orphanage which provides shelter for the children of parents who have died from HIV/AIDS. “Before we didn’t have enough money to by supplies. Now we do. We couldn’t afford the level of training. Now we are being challenged to maintain higher standards.”

El Salvador’s prison system is another area in which the Fund is making a difference. Esperanza, the main prison for men in San Salvador was designed for 800 inmates. Today, it houses 4,000—many of them violent gang members. The threat from aids has provided an opportunity for social rehabilitation through support groups and to bring warring factions together in a struggle for mutual survival. “I told them God will decide when you die, but it is not going to be now,” says Anna Parada Estrella, a doctor working inside the prison system. “The support groups began to change their character.” The program is also active in San Salvador’s women’s prison, which is inhabited to a large degree by girl friends and wives of gang members.  Many of these women had little understanding of what they were getting into and even less of an understanding of the danger from HIV/AIS.  For many  prison has also turned out to be an opportunity for a crucial education about HIV/AIDS and life and how to deal with both. The Fund’s experience provides a lesson for the humanitarian community that may be just as important: the projects that work best are the ones that come from the community itself, and sometimes it only takes a small well-targeted investment from the outside to get the ball rolling.