In 2011, the Political Declaration on HIV and AIDS called on the international community to mobilise between $22 billion and $24 billion for the global HIV response in low- and middle-income countries by 2015.1
The world is almost in reach of achieving this target with an estimated $20.2 billion made available in 2014 and a projected $21.7 billion by the end of 2015.2
UNAIDS’ new and ambitious Fast-Track approach commits to ending the global HIV epidemic as a public health threat by 2030. In order to achieve this, an estimated $31.9 billion will be required for the HIV response in 2020 and $29.3 billion by 2030.3
As a result, there is a lot more emphasis on countries most affected by the HIV epidemic to finance their own responses and find more efficient and cost-effective ways to do so.
Source of HIV and AIDS funding
In 2014, domestic sources accounted for the majority of global HIV funding (57%).3
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.4 South Africa mostly funds its own response and spends over $1 billion annually on its HIV and AIDS programmes.5
Between 2009 and 2014, 84 out of 121 low- and middle- income countries increased their domestic HIV spending. Of these countries, 46 reported a more than 50% increase in investments, with 35 countries increasing their domestic spending by more than 100%.3
However, many low- and middle- income countries remain heavily dependent upon international donors to finance their HIV response. In 2014, 44 countries had 75% or more of their HIV financing needs provided by external sources.3
HIV funding by donor governments is provided through both bilateral and multilateral channels and sometimes a mix of the two.
In 2014, the United States accounted for the majority of bilateral and multilateral funding from donor governments (64.5%), followed by the UK (12.9%), France (3.7%), Germany (3.2%) and the Netherlands (2.5%). Since 2006, these five countries have accounted for roughly 80% of all HIV funding from donor governments.1
In 2014, disbursements for HIV by donor governments was $8.64 billion – a less than 2% increase on 2013 levels ($8.49 billion).1
Most of this increase can be attributed to the UK, which increased both its bilateral support and its contribution to the Global Fund. Without the UK increase, disbursements would have declined. Total funding from other major donor governments including the United States, the largest donor, either declined or remained stable.1
Bilateral funding (funds disbursed by donor governments directly to a recipient country) accounted for 73% of HIV funding from donor governments in 2014 ($6.3 billion) – down $100 million on 2013 ($6.4 billion).1
- President’s Emergency Plan for AIDS Relief (PEPFAR), USA
The President's Emergency Plan for AIDS Relief (PEPFAR) started as a five year (2003-2008), $15 billion commitment by the US government to tackle the global HIV and AIDS epidemic.6
Since 2003, PEPFAR has spent $65 billion on programmes globally to combat HIV and AIDS, tuberculosis, malaria and other opportunistic infections.7 PEPFAR is the largest healthcare initiative to be launched by one country to address one disease.6
- Department for International Development (DFID), UK
In 2014, the UK government contributed 12.9% of all bilateral aid for HIV. DFID is primarily responsible for distributing the UKs foreign aid. Between 2008 and 2013, DFID’s overall spend, including both bilateral and multilateral funding, averaged £300 million a year.8
Roughly 60% of DFID’s multilateral HIV funding is distributed through the Global Fund to Fight AIDS, Tuberculosis and Malaria. The World Bank and UNAIDS receive most of the UK’s 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.8
In 2014, 27% of international HIV assistance ($2.3 billion) was provided through multilateral organisations such as the Global Fund, UNITAID and other United Nations agencies. Multilateral funding increased by roughly $250 million on 2013 figures ($2.1 billion).1
Several donor governments recently increased their contributions to the Global Fund and are now preferring to spend through multilateral rather than bilateral channels. In 2014, six donors provided the majority of their HIV funding through the Global Fund (Canada, the European Commission, France, Germany, Italy and Japan).1
- The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM)
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."9
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% increase on funds raised at the previous pledging conference in 2010.10
The GFATM is the world's largest financier of HIV and AIDS, TB and malaria programmes. In 2014, 55% of its total disbursements went towards HIV and AIDS programmes. The USA is the largest donor to the Global Fund followed by the UK, France, Germany and Japan.11
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.12
In 2014, HIV funding provided through UNITAID totalled $117 million – 49% of its total disbursements. France was the largest donor to UNITAID.1
- 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 $5 billion to HIV and AIDS programmes worldwide. The World Bank remains a significant financier for HIV and AIDS - in 2015, its HIV budget was $2.1 billion.13
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.13
- The private sector
Private philanthropic organisations provided $592 million for global HIV and AIDS programmes in 2013 – an 8% decrease on 2012 ($636 million). The majority of which came from US-based ones (73%), followed by EU-based ones (22%) with a further 5% coming from philanthropies elsewhere.14
Private philanthropies include foundations, corporations, faith-based organisations, non-government organisations (NGOs) and individuals. As well as providing funding for the global HIV response, many of these organisations provide other non-financial support such as price reductions for HIV treatment.1
- The Bill & Melinda Gates Foundation
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. In 2013, the foundation provided 49% of all US HIV-related philanthropic giving.14
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. The foundation concentrates its spending in places where existing funds are scarce and will therefore have the greatest impact.15
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.16
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.17
However, some believe that this new method will lower the allocation shares to countries who rely on this funding. For example, countries like Haiti (which has still not recovered from the 2010 earthquake), and Ukraine (currently having major economic difficulties), face major cuts to their allocations. It is argued that donors should take local circumstances into account, otherwise it could hinder global efforts to fight HIV.18
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, while the Global Fund directly allocates the vast majority of its funding (85%), the remaining 15% is distributed via "counterpart financing".19
To be eligible for this funding, 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% for low- income countries, 20% for "lower" low- and middle-income countries, 40% for "upper" low- and middle-income countries and 60% for upper-middle income countries.20
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.21
By geography and HIV prevalence
Many HIV and AIDS donors have a history of targeting their spending by geography, typically 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% 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.22
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.23 These surveys are often the only representation of national HIV prevalence, and if they are not accurate, it makes measuring and targeting subnational populations even more difficult.24
By key affected populations
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 populations most susceptible to HIV transmission.25
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”.26 Targeting specific populations at risk of HIV transmission (such as men who have sex with men (MSM) and people who inject drugs (PWID)) has proved highly effective and efficient in a number of countries.27 28 29
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.21
Human rights work plays a vital role in protecting populations most affected by HIV. However, in 2013, only $137 million was spent on the global human rights response to HIV accounting for just 0.13% of all HIV spending in low- and middle-income countries.30 Moreover, a 2014 UNAIDS study found that 59% of civil society organisations implementing human rights programmes reported decreases in funding.31
Funding for harm reduction programmes that target drug users also 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% of what is required.32
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.33
Since the mid-2000s, roughly half of all combined HIV spending from both international and domestic sources has funded treatment, care and support programmes. However, the balance between spending on programme areas differs by country, its economic situation and the type of epidemic. For example, upper-middle income countries spend a higher share on treatment because they face higher antiretroviral drug prices.2
In areas such as HIV prevention research and development (R&D), global HIV spending has stagnated and even declined. Between 2013 and 2014, funding for HIV prevention R&D fell by 1% to $1.25 billion. North America provides the vast majority of HIV prevention R&D investment (90.9%).33
Closing the HIV resources gap
By 2015, an estimated $22-24 billion will be required to address the global HIV epidemic in low- and middle-income countries. The latest projections suggest that investments will fall just short of this target.2
With future targets demanding an extra $12 billion annually by 2020 and $8 billion by 2030, investments need to be front-loaded (rapidly scaled up) for the next five years to ensure the long-term sustainability of the HIV response.2
New World Health Organisation (WHO) treatment guidelines now recommend that all people living with HIV start treatment regardless of CD4 count, which is likely to impact significantly upon the future cost of the global HIV response.2 This, coupled with the stagnation of donor funding is demanding that interventions are cost-effective and efficient. As domestic funding for HIV has 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’ emphasises country ownership, efficiency and sustainable financing of the HIV response. It is one example reflecting increasing political commitment to these principals.34 Likewise, the ‘Arab Strategic Framework for the Response to HIV and AIDS (2014–2020)’ aims to increase reliance on domestic sources for the HIV response in all Arab countries by 80% by 2020.35
A number of 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.36
Photo credit: ©iStock.com/hidesy
- 1. a. b. c. d. e. f. g. h. i. UNAIDS & The Henry J. Kaiser Family Foundation (2015) 'Financing the Response to HIV in Low- and Middle-Income Countries: International Assistance from Donor Governments in 2014'
- 2. a. b. c. d. e. UNAIDS (2015) 'How AIDS Changed Everything'
- 3. a. b. c. d. UNAIDS (2015) 'Fact sheet: 2014 statistics'
- 4. African Union & UNAIDS (2013) 'Delivering Results Toward Ending AIDS, Tuberculosis and Malaria: African Union Accountability Report on Africa–G8 Partnership Commitments'
- 5. Maurice, J. (2014) 'South Africa's battle against HIV/AIDS gains momentum' The Lancet 383(9928):1535-1536
- 6. a. b. President's Emergency Plan For AIDS Relief (PEPFAR) 'About PEPFAR' [accessed 27 October 2015]
- 7. President's Emergency Plan For AIDS Relief (PEPFAR) 'PEPFAR Funding' [accessed 27 October 2015]
- 8. a. b. Department for International Development (DFID) (2013) 'Towards Zero Infections - Two Years On A Review of the UK’s Position Paper on HIV in the developing world'
- 9. The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) 'The Framework Document' [accessed 27 October 2015]
- 10. The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) 'Resource Mobilization' [accessed 27 October 2015]
- 11. The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) 'Grant Portfolio, Portfolio Overview' [accessed 27 October 2015]
- 12. UNITAID (2012) 'UNITAID 5 Year Evaluation Summary'
- 13. a. b. The World Bank (2015) 'HIV and AIDS Overview'
- 14. a. b. Funders Concerned About AIDS (FCAA) (2014) 'Philanthropic Support to Address HIV/AIDS in 2013
- 15. Bill & Melinda Gates Foundation 'HIV: Strategy Overview'
- 16. Glassman, A. et al (2013) 'More Health for the Money: Putting Incentives to Work for the Global Fund and Its Partners'
- 17. The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) 'Funding Model: Allocations’[accessed 27 October 2015]
- 18. Devnani, M. et al (2015) ‘Global HIV Funding And Local Contexts’ Health Affairs 34(2):359
- 19. The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) ‘Counterpart Financing’ [accessed 27 October 2015]
- 20. The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) (2014) 'Grant Management Platform: Concept Note Content Guidance'
- 21. a. b. Fan, V. et al (2014) 'How A New Funding Model Will Shift Allocations From The Global Fund To Fight AIDS, Tuberculosis, And Malaria' Health Affairs 33(12)
- 22. Institute of Medicine (IOM) (2013) 'Evaluation of PEPFAR'
- 23. Hogan, D.R. et al (2012) 'National HIV prevalence estimates for sub-Saharan Africa: controlling selection bias with Heckman-type selection models' Sexually Transmitted Infections 88:17-23
- 24. Brookmeyer, R. (2010) 'Measuring the HIV/AIDS epidemic: approaches and challenges' Epidemiologic Reviews 32(1):26-37
- 25. Rowthorn, R. et al (2009) 'Optimal control of epidemics in metapopulations' Royal Society Interface 6(41):1135-1144
- 26. UNAIDS (2011) 'A New Investment Framework for the Global HIV Response'
- 27. Vassall, A. et al (2014) 'Cost-effectiveness of HIV prevention for high-risk groups at scale: an economic evaluation of the Avahan programme in south India' The Lancet: Global Health 2(9):531-540
- 28. Remme, M. et al (2014) ‘The cost and cost-effectiveness of gender-responsive interventions for HIV: a systematic review’ Journal of the International AIDS Society 17:19228
- 29. Juusola, J.L. et al (2012) 'The cost-effectiveness of preexposure prophylaxis for HIV prevention in the United States in men who have sex with men' Annals of Internal Medicine 156(8):541-550
- 30. UNAIDS (2015) 'Sustaining the human rights response to HIV: An analysis of the funding landscape and voices from community service providers'
- 31. UNAIDS (2014) 'The Gap Report'
- 32. International Harm Reduction Association (IHRA) (2014) 'The funding crisis for harm reduction: Donor retreat, government neglect and the way forward'
- 33. a. b. HIV Vaccines & Microbicides Resource Tracking Working Group 'HIV Prevention Research & Development Funding Trends, 2000-2014: Investing in innovation in an evolving global health and development landscape'
- 34. African Union (2012) 'Roadmap on Shared Responsibility and Global Solidarity for AIDS, TB and Malaria in Africa'
- 35. Social Affairs Sector - Directorate of Health and Humanitarian Aid Technical Secretariat of the Council of Arab Ministers of Health, League of Arab States (2014) ‘Arab Strategic Framework for the Response to HIV and AIDS (2014–2020)’
- 36. UNAIDS (2013) 'Efficient and Sustainable HIV Responses: Case studies on country progress'