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Funding for HIV and AIDS

United States Secretary of State Hillary Clinton unveils the PEPFAR Blueprint: Creating an AIDS-free Generation, World AIDS Day 2012

In 2013, funding for the global HIV and AIDS response reached its highest ever level with an estimated $19.1 billion made available for programmes in low and middle-income countries. 1

However, though progress has been made in mobilising resources for the response, the increasing number of new HIV infections in many countries coupled with stagnating international assistance is increasing the need for more innovative funding mechanisms and new sources of domestic funding. 2 With an estimated $22-24 billion needed to address the global HIV epidemic in 2015, a significant resources gap is anticipated. 3

In 2013, funding from donor governments actually fell to $8.07 billion - a 3 percent drop on 2012. This drop was primarily the result of declining annual commitments by the United States government - the world's largest HIV donor. However, disbursements (resources made available to the field) increased by 8 percent to $8.46 billion. 4

In 2012, 47 percent of all HIV spending was in sub-Saharan Africa followed by Latin America (17 percent). 5

Sources of HIV and AIDS funding

Domestic sources

In 2012, domestic sources accounted for the majority of global HIV funding (53 percent) - $9.9 billion. 6

Low and middle-income countries are now beginning to lead on efforts to tackle to HIV epidemic. In sub-Saharan Africa, countries such as Kenya, South Africa, Togo and Zambia have dramatically increased their domestic HIV spending in recent years. 7 South Africa mostly funds its own response and spends over $1 billion annually on its HIV and AIDS programmes. 8

In 2012, over two-thirds of low and middle-income countries increased domestic spending on HIV and some, including Chad, Guinea, Sierra Leone and Kyrgyzstan doubled their domestic HIV spend. 9

However, low-income countries remain heavily dependent upon international financing for their HIV responses with domestic resources accounting for just 16 percent of all HIV funding. 10

Donor governments

In 2012, international investment in HIV programmes by donor governments was an estimated $8.9 billion - an 8 percent increase on 2011. Bilateral funding (funds disbursed by donor governments directly to a recipient country) accounted for 67 percent of all international HIV funding. 11

The United States provided the majority of bilateral funding followed by the UK (10.7 percent), the Netherlands (2.8 percent), Denmark (2.6 percent) and Germany (2.4 percent). In the same year, the UK, Denmark, the Netherlands, Ireland, Norway and Sweden contributed a share to international HIV funding greater than their respective share of global gross domestic product. 12

  • President’s Emergency Plan for AIDS Relief (PEPFAR), USA

    George W Bush signs the PEPFAR initiative, 2003

The President's Emergency Plan For AIDS Relief (PEPFAR) was initially a five year (2003-2008), $15 billion commitment by the US government to tackle the global HIV and AIDS epidemic. In July 2008, PEPFAR was renewed and intended to spend $48 billion between 2009 and 2013 on programmes globally to combat HIV and AIDS, tuberculosis and malaria. PEPFAR is the largest healthcare initiative to be launched by one country to address one disease. 13

In 2012, PEPFAR accounted for 73 percent of all bilateral aid for HIV, 49 percent of all international HIV assistance and 23 percent of total HIV funding. 14

  • Department for International Development (DFID), UK

In 2012, the UK government contributed 10.7 percent of all bilateral aid for HIV. The Department for International Development (DFID) is primarily responsible for distributing the UKs foreign aid.

Though DFID provides funding for a wide range of development projects, addressing the global HIV and AIDS epidemic is among its principle goals accounting for 7.1 percent its budget. 15 Between 2008 and 2013, DFIDs overall spend, including both bilateral and multilateral funding, averaged £300 million a year. 16

Roughly 60 percent of DFIDs multilateral HIV funding is distributed through the Global Fund. The World Bank and UNAIDS receive most of the UKs remaining multilateral funds. The UK has recently committed up to £1 billion for the Global Fund 2014-2016 replenishment which will see the UKs annual multilateral fund commitments increase significantly to £500 million annually. 17

Multilateral organisations

In 2012, 28 percent of international HIV assistance was provided through multilateral organisations such as the Global Fund, UNITAID and other United Nations agencies. Multilateral funding accounted for 13 percent of all funding for HIV. 18

Several donor governments recently increased their contributions to the Global Fund and are now preferring spend through multilateral rather than bilateral channels. For example, in 2013, five donors provided the majority of their HIV funding through multilateral channels (such as Global Fund and UNITAID): France (88 percent), European Commission (81 percent), Canada (70 percent), Japan (69 percent), and Germany (53 percent). 19

  • The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) Mark Dybul, Executive Director at The Global Fund

Founded in 2002, the GFATM is an international financing organisation that aims to "attract and disburse additional resources to prevent and treat HIV and AIDS, tuberculosis and malaria." 20 The GFATM is the world's largest financier of HIV and AIDS, TB and malaria programmes. In 2013, contributions to the Global Fund amounted to $3.3 billion. 21

At the end of 2013, the Fourth Replenishment of the Global Fund saw governments and private sector donors commit $12 billion to fund HIV and AIDS programmes from 2014 to 2016. This fell short of the $15 billion target but represented a 30 percent increase on funds raised at the previous pledging conference in 2010. 22 The USA was the largest donor to the Global Fund followed by France, Germany and the UK.

  • UNITAID

UNITAID is a global health initiative that provides sustainable financing to tackle inefficiencies in markets for medicines, diagnostics and prevention for HIV and AIDS, malaria and tuberculosis. 23

In 2013, funding for UNITAID totalled $262 million. France was the largest donor to UNITAID. 24

  • The World Bank

The World Bank was a leader in global HIV and AIDS spending in the early days of the epidemic. Since 1989, the World Bank has provided $4.6 billion to HIV and AIDS programmes worldwide. 25 The World Bank remains a significant financier for HIV and AIDS - in 2013, its HIV budget was $1.5 billion. 26

As well as financing HIV prevention, treatment and care programmes, the World Bank supports countries to do "better for less". Specifically, it provides technical assistance to increase the efficiency, effectiveness and sustainability of national responses to the epidemic. 27

The private sector

In 2012, private and philanthropic funders from the US and the European Union contributed more than 5 percent of international HIV disbursements. 28 These include foundations, corporations, faith-based organisations, non-government organisations (NGOs) and individuals. 29

Philanthropies provided $636 million for global HIV and AIDS programmes in 2012, the majority of which coming from US-based ones ($467 million), followed by EU-based ones ($147 million) with $38 million coming from philanthropies elsewhere. 30

  • The Bill & Melinda Gates Foundation A scientist conducting HIV research at The Gates Foundation

Among foundations, the Bill & Melinda Gates Foundation is the leading philanthropic funder of international HIV efforts. In fact, it is one of the largest private foundations in the world and aims primarily to enhance healthcare and reduce extreme poverty. 31

To date, the foundation has provided more than $2.5 billion to tackling the global HIV epidemic and has given an additional $1.4 billion to the Global Fund. Though the foundations resources are large for a philanthropic organisation, they represent a small proportion of global HIV funding compared to what donor and domestic governments spend to combat the epidemic. As a result, the foundation concentrates its spending in places where existing funds are scarce will therefore have the greatest impact. 32

How is global HIV and AIDS funding allocated?

By country demand

Initially, multilateral funding for the global HIV response was allocated by country demand.

Between 2002 and 2011, the Global Fund allocated its HIV and AIDS resources by "demand" and "country requests" and disbursed its resources on a "first come, first serve" basis. Under this system, the most ambitious proposals tended to receive grants regardless of the effectiveness of the chosen intervention, its cost-effectiveness or efficiency. 33

Since 2012, the Global Fund has based the distribution of HIV funds on "country need" and more specific objectives to control the spread of HIV. Instead of "first-come, first-serve", the new funding mechanism uses an "allocation methodology" based on criteria such as HIV prevalence and a recipient country's ability to finance its response. 34

By a recipient country's finances

Under other systems, a country's own contribution to its HIV and AIDS programmes determines how much assistance they receive from donors.

For example, the Global Fund utilises "counterpart financing". Under this policy, a country (or 'counterpart') has to commit a minimum level of funds towards its national HIV programmes as a share of government and Global Fund investments. The counterpart financing threshold is currently set at 5 percent for low income countries, 20 percent for "lower" low and middle-income countries, 40 percent for "upper" low and middle-income countries and 60 percent for upper-middle income countries. 35

Some have argued that counterpart financing, in conjunction with the Global Fund's country allocations, constrain a country's HIV budget by setting both a lower and upper limit. 36

By geography / HIV prevalence

Many HIV and AIDS donors have a history of targeting their spending by geography, generally by HIV prevalence and incidence among the general population.

In 2009, PEPFAR were providing funding to 88 countries globally, 15 of which were categorised as 'focus countries'. Focus countries (which were mainly high prevalence, high population countries in sub-Saharan Africa) accounted for 90 percent of the organisation's bilateral funding between 2004 and 2011.

In 2013, an Institute of Medicine report said that PEPFARs funding priorities did not completely reflect the global HIV burden - defined by the number of HIV cases and HIV prevalence. For example, three focus countries - Rwanda, Haiti and Guyana received a disproportionate share of PEPFAR funding considering their small populations and number of HIV cases. By comparison, Swaziland, which has the highest HIV prevalence in the world, received the least amount of money among PEPFAR focus countries. Between 2004 and 2011, PEPFAR spent $635 million in Rwanda compared to just $126 million in Swaziland. 37

A number of studies have more fundamental concerns about estimations of HIV prevalence, particularly in regions like sub-Saharan Africa where there are varying levels of participation in Demographic Health Surveys. 38 These surveys are often the only representation of national HIV prevalence, and if they are not accurate, this makes subnational populations even more difficult to measure. As a result, it can be difficult to target resources at the subnational level. 39

By key affected populations

With a global HIV resources gap anticipated, funders of the response have been exploring ways to increase the impact and efficiency of HIV and AIDS programmes. Many have suggested aiming resources at key affected groups most susceptible to HIV transmission. 40

Since 2011, the UNAIDS investment framework has encouraged countries to prioritise their spending on country epidemiology (where HIV affects certain groups) to produce “substantial and lasting effects on the HIV/AIDS epidemic”. 41 Targeting specific populations at risk of HIV transmission (e.g. men who have sex with men (MSM), people who inject drugs (PWID)) has proved highly effective and efficient in a number of countries. 42 43 44

However, targeting these groups is particularly challenging partly because of the high levels of stigma and discrimination they face with organisations such as UNAIDS, remaining almost completely reliant upon countries to provide this data. 45

More generally, the level of funding for HIV prevention initiatives targeting key affected groups has been heavily scrutinised. For example, many argue that funding for harm reduction programmes for drug users remains far below estimated need. UNAIDS estimates that $2.3 billion is needed to fund HIV prevention initiatives for people who inject drugs in 2015. In 2010, international donors invested just $160 million - 7 percent of what is required. 46

What is the money spent on?

Since the early 1990s, HIV funding priorities have shifted dramatically. Initially, donors put a large proportion of their funding into research for an HIV vaccine. With the development of life-saving antiretroviral treatment (ART), efforts have increasingly focussed on providing people living with HIV in low and middle-income countries with the appropriate treatment and care. 47 Red AIDS ribbon on paper bills

By 2012, treatment and care services accounted for 55 percent of global HIV spending followed by prevention (19 percent) and programme management and administration (12 percent). 48 Domestic sources accounted for the majority of spending on treatment and care with international assistance financing the majority of prevention interventions. 49 The proportion of global HIV spending on treatment and care has increased dramatically over the past decade.

However, in areas such as HIV prevention research and development (R & D), global HIV spending has stagnated and even declined. Between 2012 and 2013, funding for HIV prevention R & D fell by 4 percent. This fall was mainly the result of declining US investment which funds roughly 70 percent of the total global investment into HIV prevention R & D. Investment from European funders as well as philanthropic ones also fell. 50

Closing the HIV resources gap

By 2015, an estimated $22-24 billion of funding is required to address the global HIV epidemic in low and middle-income countries.

While this target is not out of reach, new 2013 World Health Organisation (WHO) guidelines on antiretroviral treatment (ART) (which make people with CD4 counts under 500 eligible for ART) are expected to increase the amount of HIV funding required significantly - between 5 and 10 percent by 2025. 51

The stagnation of donor funding and the impending resource gap is demanding that interventions are cost-effective and efficient. With domestic funding for HIV having now overtaken international assistance, there is greater emphasis on affected countries to implement these types of strategies. The African Union's "Roadmap on Shared Responsibility and Global Solidarity for AIDS, TB and Malaria in Africa" which emphasises country ownership, efficiency and sustainable financing of the HIV response is one example reflecting increasing political commitment to these principals. 52

Indeed, affected countries have already utilised a range of strategies to increase the efficiency and sustainability of their HIV and AIDS programmes. For example, Cambodia has re-allocated its existing resources to high-impact, targeted interventions. In South Africa, billions of Rands have been saved by dramatically improving the antiretroviral drug tendering process. Kenya and Kazakhstan have set up their future HIV funding mechanisms in anticipation of receiving fewer external funds from donors in the coming years. 53

 

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