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Funding for HIV and AIDS

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KEY POINTS:

  • To be on course to end AIDS as a public health threat by 2030, UNAIDS estimated that US $26.2 billion was required for the global HIV response in 2020 alone. At the end of 2019 only US $ 18.6 billion was available – just 71% of what was needed.
  • To get the global AIDS response back on course UNAIDS is calling for yearly HIV investments in low- and middle-income countries to rise to a peak of US $ 29 billion by 2025.
  • In recent years, the amount of money for the HIV response in low- and middle-income countries has reduced.
  • Philanthropic donations are at their largest since records began, but still only account for 2% of the resources available for the HIV response in low- and middle-income countries.
  • Domestic funding for the HIV response now exceeded funds provided by international donors, accounting for 57% of the global funding total in 2019. In the face of donor stagnation there is increasing emphasis on countries most affected by HIV to finance their own responses and find more efficient and cost-effective ways to do so.
  • Despite the fact that 62% of all new HIV infections among adults occur among key populations and their partners, just 2% of all HIV funding is spent on these groups.

Explore this page to find out more about sources of HIV and AIDS funding, how international funding is allocated, how funding could be spent more effectively and the future of funding for the HIV response.

The huge mobilisation of resources for the global HIV and AIDS response over the course of the epidemic has been unprecedented in the history of public health. The challenge of funding HIV treatment, prevention and care in middle- and low-income countries has been characterised by vocal advocacy, unique and innovative funding mechanisms, previously unseen levels of bilateral (direct government-to-country) aid, and philanthropic donations whose scale have rivalled those of donor governments and multilateral institutions.

However, recent years have seen a regression. Resources for HIV responses in low- and middle-income countries have been decreasing since 2018. As a result, none of the global targets set by UNAIDS for 2020 were met. Additionally, it is estimated that an additional 3.5 million people contracted HIV and an additional 820,000 people died of AIDS-related illnesses between 2015 and 2020.1

National governments in some low- and middle-income countries are now stepping up to fund their own responses, slowly filling some funding gaps and working towards a more sustainable response to HIV.2

UNAIDS’ ambitious Fast-Track approach —endorsed by the UN General Assembly in the 2016 Political Declaration on Ending AIDS—has committed to ending the global HIV epidemic as a public health threat by 2030. In order to achieve this, UNAIDS estimated that an annual investment of US $26.2 billion would be required for the HIV response in 2020, steadily decreasing to $23.9 billion by 2030.3

However, increases in resources for HIV responses in low- and middle-income countries stopped in 2017, with funding decreasing by 7% between 2017 and 2019.4 At the end of 2019, only US $ 18.6 billion was available for the HIV response in low- and middle-income countries – just 71% of the 2020 target.5 As a result, UNAIDS now estimates that annual investments will need to rise to US $ 29 billion by 2025 to get the AIDS response back on track in low- and middle-income countries.6

The future outlook of global funding for the HIV response remains uncertain. Funding provided by the USA, the largest contributor to the global response, rose by 50% between 2010 and 2017 then dropped by 8% over the next two years, resulting in a 38% increase overall (from US $ 3.5 billion in 2010 to US $ 4.8 billion in 2019). Investments from the Global Fund to Fight AIDS, Tuberculosis and Malaria rose by 26% between 2010 and 2017, then declined by 15% in 2018 and 2019, resulting in a 7% increase over near years. Other international sources have halved over the same nine-year period.7

In 2021, the UK, another major international donor, reduced the annual funding it provides to UNAIDS to respond to HIV in low- and middle-income countries by more than 80%, from GBP £15 million to GBP £2.5 million.8

There is now a lot more emphasis on countries most affected by HIV to finance their own responses and find more efficient, innovative and cost-effective ways to do so.

We are not on track to end AIDS by 2030, but our modelling shows that spending wisely and focusing investment in the right place will have remarkable results and get us on track to end AIDS by 2030. We must not repeat the mistakes of the past. The time to invest is now.

– Jose Izazola, UNAIDS Special Adviser, Resource Tracking and Finances9

Sources of HIV and AIDS funding

Domestic resources

Domestic funding is HIV spending by country governments in their national budgets. Historically, the HIV response has been largely funded by international donors and governments. Low-income countries still mainly rely on international funding to respond to HIV, while many lower-middle-income countries are struggling to provide enough domestic resources to fill the gap caused by the withdrawal of international funding. In upper-middle-income countries, domestic resources are now the predominant source of investment.10

In 2019, domestic resources exceeded funds provided by donors and accounted for the majority of global HIV funding (57%), totalling US $10.6 billion.11The amount of domestic investment low- and middle income countries are making in responding to HIV has grown by 50% between 2010 and 2019.12Although challenging for low- and middle-income countries, shifting towards domestic funding has advantages. These include fostering ownership and accountability in the implementation of the national HIV response and increasing their sustainability.13

Some wealthier countries are progressively contributing more domestic resources to the HIV response. For example, India funds more than 90% of its national HIV programme (up to the year 2021).14 while South Africa, funds 70% of its response.15. In East and Southern Africa, the region worse affected by HIV in the world, external sources fund 59% of the HIV response. With the exception of South Africa, countries rely on external sources for about 80% of their HIV funding.16

In Asia and the Pacific, domestic funding for the HIV response increased by 87% between 2010 and 2019, while international investments fell by 63%. As domestic resources often prioritise funding for HIV treatment, declines in international support have mostly affected HIV prevention services for key populations, meaning the costs of treatment are likely to rise in the future.17

Case study: Transitional funding in Vietnam

International funds for HIV programmes in Vietnam are decreasing as the country moves from a low-income to lower middle-income status. As a result, Vietnam’s HIV response is increasingly financed domestically. In 2019, domestic resources supported 49% of Vietnam’s HIV response, compared to 35% in 2015.18

To cover rising costs, the Vietnamese government has invested in finding more sustainable way to ensure it can fund HIV treatment.  It has centralised the procurement of antiretrovirals (ARVs), and is funding costs through its Social Health Insurance (SHI) fund. SHI is a national insurance scheme that is compulsory for those in formal employment but voluntary for others.19 Certain groups of people who are not formally employed and cannot afford insurance, including people with disabilities and people living with HIV, are covered by the government. Many people from key populations who are out of work, or earn income through the informal job sector, are expected to pay for themselves and cannot afford do to so, so end up going without cover.20

In 2019, 25% of the Vietnamese population was not covered by SHI.21 High costs not covered by SHI and difficulties signing up to the scheme with missing legal documents such as an identity card means that many people living with HIV were missing out on having health insurance.

“Those who don’t have a health insurance card have just two options – either they suffer or they pay out of pocket. Often the latter means borrowing money at extremely high interest, so people are spending money they should be using for food or for education for their children.” - Khuất Thị Hải Oanh, Executive Director of Vietnamese NGO the Center for Support Community Development Initiatives (SCDI).22

In 2018, campaigning from communities living with and affected by HIV resulted in the Vietnamese government making the SHI scheme available for people who don’t have ID papers.23

However, the SHI scheme does not cover HIV prevention. Domestic funding for key population prevention programmes, which includes HIV testing, case-finding and PrEP, only supports 20% of services, with international donors, mainly the Global Fund and PEPFAR, covering the rest.24 As the Global Fund continues to decrease its investment in the country as Vietnam enters transition, the government will be left to fund more of these vital services. This will be a key focus for campaigners when the SHI scheme is reviewed in 2021.25

International funding

International HIV funding from donor governments is provided through both bilateral and multilateral channels. International investment in the HIV responses in low- and middle-income countries was US $7.8 billion in 2019, US $165 million less than in 2018. This is nearly the same as the funding levels from a decade ago, despite a 25% increase in the number of people living with HIV in low- and middle-income countries during that time.26This decline was  primarily by a decrease in bilateral funding from the USA, and from seven other donor countries, although their declines had less of a significant impact due to the amount the USA provides. Although international donors increased contributions to The Global Fund to Fight AIDS, Tuberculosis, and Malaria, UNAIDS and Unitaid by more than US $100 million, these increases were not enough to make up for the shortfall.27

The USA is still the biggest funder of the HIV response, providing US $5.7 billion in 2019. The UK is the second largest donor (US $646 million), followed by France (US $287 million), the Netherlands (US $213 million) and Germany (US $180 million).28

Bilateral assistance

In 2019, 73% of donor government funding was distributed bilaterally, which means it was sent directly from a donor country to recipient country. It has fallen by almost US $300million from 2018 levels (from US $6 billion to $5.7billion).29

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

PEPFAR is the largest global commitment any country has made to address a single health issue. It initially started in 2003 as a five-year, US $15 billion commitment by the USA government to tackle the global HIV and AIDS epidemic.30Since then PEPFAR has provided US $85 billion for programmes globally to combat HIV and AIDS, tuberculosis, malaria and other opportunistic infections.31 As of September 2019, PEPFAR was supporting antiretroviral treatment (ART) for more than 15.7  million people and had funded 79.6  million HIV tests in that year alone.32

Multilateral assistance

In 2019, a total of US $2.1 billion international HIV assistance was provided through multilateral organisations such as the Global Fund, Unitaid and other United Nations agencies. This is an increase of more than US $100 million on the amount provided in 2018. 33

In 2019, funding provided to the Global Fund totalled US $1.8 billion, while Unitaid received US $99 million and UNAIDS $178million.34 Australia, Germany, Ireland, Italy, Japan, the Netherlands, the UK and the USA increased their contributions to multilateral funding, while Canada, France, Norway, Sweden, and the European Commission decreased their contributions, and Denmark kept its contribution stable.35

The Global Fund to Fight AIDS, Tuberculosis and Malaria (The Global Fund)

Founded in 2002, the Global Fund is an international financing organisation that works in partnership between governments, civil society, the private sector and people affected by HIV, tuberculosis and malaria. Its funding comes mostly from donor governments (92%), with the remainder provided by the private sector and foundations.36 It provides 21% of all international financing for HIV programmes, and has provided more than US $21.2 billion for HIV programmes in more than 150 countries between 2002 and June 2020 (excluding TB/HIV programmes).37

The Global Fund has three key criteria for allocating its funds, prioritising countries with high disease burden, countries where the proportion of key populations is highest and countries where national health systems lack capacity to respond to HIV. In 2019, it supported programmes providing ART to 20.1 million people and provided 133 million HIV tests.38

The Global Fund has been instrumental in supporting key populations in a number of ways. It appoints key population representatives to sit on Country Co-ordinating Mechanisms (CCMs), national committees that submit requests for funding on behalf of the entire country and oversee implementation once the request has been granted. It has also been instrumental in funding a large majority of key population programmes in many countries.39 For example, it is the world’s largest investor in harm reduction programmes for people who inject drugs.40 In 2019, of the 9.9 million people the Global Fund reached with HIV prevention services, such as condoms and PrEP, 5 million were people from key populations.41

In October 2019, the Sixth Replenishment of the Global Fund saw governments and private sector donors commit US $14 billion between 2020 and 2023. This was the target the Global Fund had been aiming for and it was the largest amount it had ever received, and the most a multilateral health organisation has ever raised.42

In 2020, in response to the COVID-19 pandemic, the Global Fund made more than US $1 billion available to countries it supports to respond to the pandemic, adapt their HIV, TB and malaria programmes, and strengthen overstretched health systems. This has led the fund to appeal to donor governments and other supporters for an additional US $5 billion to continue to support countries in their COVID-19 response.43

Other sources of funding

Private philanthropic organisations provided US $706 million for global HIV and AIDS programmes in 2019. Around $465 million of this money was used to support HIV responses in low- and middle-income countries (or 2% of HIV funding for these countries). The 2019 total is a 7% increase from 2018 (a rise of US $49 million). This is the most amount philanthropists have given to the HIV response since monitoring began 20 years ago.44Private philanthropies include foundations, corporations, faith-based organisations, non-government organisations 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.45

The top 20 funders account for 92% of 2019 philanthropic resources, with the two largest funders — The Bill and Melinda Gates Foundation and Gilead Sciences representing over half of all philanthropic funding in 2019. The annual rise was mainly driven by an increase from one of the top 20 funders; a US $100 million investment in HIV research from the Phillip T. and Susan M. Ragon Foundation. If this had not been provided, philanthropic funding would have decreased by 4% overall.46 Furthermore, HIV-related philanthropy to low- and middle-income countries fell by one-third between 2018 and 2019, despite most people living with HIV living in these countries. Philanthropic funding for key populations also fell by 12% over the same period.47

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 2019, the foundation provided 31% of all HIV-related philanthropic giving.48To date, the foundation has committed more than US $3 billion in HIV grants to organisations around the world and has given an additional US $3 billion to the Global Fund. The foundation concentrates its spending in places where existing funds are scarce and will therefore have the greatest impact.49

Innovative funding mechanisms

The global HIV response has inspired a number of innovative funding models. One example is Unitaid’s ‘airline solidarity contribution’. This is a domestic tax that participating countries add to airline tickets to help fund HIV programmes. Countries participating in the scheme include South Korea, Madagascar, Mauritius, Niger and Côte d’Ivoire.50

Another example is the Global Fund’s Debt2Health programme, which launched in 2007 to generate additional domestic resources for health financing through ‘debt swaps’. Under this programme, developing countries can forgo repayment of a portion of their sovereign debt on the condition they invest an agreed amount in their health system through the Global Fund. To date, debts swapped under Debt2Health agreements total around US $140 million (as of September 2020), involving Australia, Spain and Germany on the creditor side; Cameroon, Côte d'Ivoire, Democratic Republic of Congo, El Salvador, Egypt, Ethiopia, Indonesia and Pakistan on the beneficiary side.51

The Global Fund also run the (RED) scheme, which has generated over US $650 million for the HIV response in Africa. Through the scheme global commercial brands and organisations have developed (RED)-branded products and services that, when bought, provide money for the Global Fund.[Ibid.

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How is international HIV and AIDS funding allocated?

International HIV and AIDS funding is allocated in a number of ways and has changed over time. In recent years, funders of the HIV response have been exploring ways to increase the impact and efficiency of HIV and AIDS programmes with many starting to aim resources at populations most at risk of HIV.

How does the Global Fund allocate its resources?

Between 2002 and 2011, the Global Fund allocated its HIV resources on the basis of demand and country requests, and it disbursed its resources on a first come, first served 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.52

From 2012 to 2016, the Global Fund based the distribution of HIV funds on country need and more specific objectives to control the epidemic. This approach was based on criteria such as HIV prevalence and a recipient country's ability to finance its own response.53

In 2016 the Global Fund changed the way it allocates funds to give greater priority to low-income/high burden countries. Once a country reaches upper-middle-income status, it is no longer eligible for Global Fund grants unless its disease burden continues to be classified as high. These countries go through a process known as ‘transitional funding’, as they shift from Global Fund grants toward full domestic funding for health programmes. Concerns have been raised regarding the effect transition may have on the HIV response. The Global Fund Advocates’ Network argues that using a country’s income level as a measure of its ability to sustain a public health response does not factor in that country’s willingness and ability to absorb programmes into its domestic funding and operational structures. Additionally, while many governments have shown a strong willingness to fund HIV treatment, very few have stated their commitment to continuing and expanding community-based prevention programmes aimed at key populations, the people who are most affected by HIV.54

The Global Fund current allocation approach (for 2020-2022) still focuses on higher burden, lower income countries with an explicit emphasis on HIV epidemics among key and vulnerable populations and providing sustainable and paced reductions in countries where it is decreasing funds.55 Approximately 74% of disbursements in the current funding cycle went to countries in sub-Saharan Africa, the place in the world most affected by HIV.56

Between 15-30% of the money the Global Fund provides to countries is provided as a ‘co-financing incentive’, which requires the country to invest additional domestic resources in its HIV response to access the money.57 To be eligible for this funding, a country has to commit a minimum level of funds towards its national HIV programmes as a share of government and Global Fund investments. Some have argued that co-financing, in conjunction with the Global Fund's country allocations, constrain a country's HIV budget by setting both a lower and upper limit.58

Case study: The impact of Global Fund in Eastern Europe

The transitioning system of the Global Fund, in which upper-middle-income countries have funding slowly withdrawn, has particularly hit Eastern Europe. After the system was introduced, harm reduction services collapsed in Albania, Bosnia and Herzegovina, Bulgaria, Romania and Serbia.

Elsewhere in the region, the quality of harm reduction services have been decreasing even if services are still available. In Ukraine, for example, the cost of needle and syringe programmes has fallen from around US $ 46 per person per year in 2012 to less than US $20 in 2020 and covers fewer HIV and TB tests, consultations, syringes and condoms than before.

To try and address the situation, the Global Fund has committed to giving transitioning countries more time to prepare for taking over the funding of services. Under the scheme, the Global Fund provides a cushion to ease the impact of funding withdrawal by investing in strengthening the country’s health system to make it more sustainable. Advocates argue that a new mechanism should be introduced to ensure that countries have the required capacity to maintain and scale-up their HIV response once they are no longer eligible for international investment and to limit the damage of failed transitions.59

How does PEPFAR allocate its resources?

PEPFAR funds and operates programmes in more than 50 countries. However, in 2017 PEPFAR announced its next three-year strategy would mainly focus its funds on 13 countries most affected by HIV, all of which had the systems in place to gain control of their epidemics by 2020. When it made this announcement, PEPFAR didn’t specified what percentage of its funds would go to these 13 countries or by how much the budget for other PEPFAR countries would be  reduced by.60

How do other funders allocate their resources?

Unitaid is a global health initiative that aims to increase access to affordable treatment and prevention of HIV and AIDS, malaria and tuberculosis. The organisation intervenes to open up new health markets in order to expand supply, improve quality, stimulate development of new and better projects, while bringing prices down. In 2010, Unitaid established the Medicines Patent Pool (MPP) to hold patents of ARV and other medication. This allows the MPP to manufacture these drugs more cheaply for distribution in low- and middle-income countries. Due to the MPP, yearly HIV treatment costs around US $70 in Africa, compared to US $10,000 in Europe. Due to the price reductions of medication and other products, Unitaid’s investments in MPP have resulted in savings that are 10.9 times the value of the funding provided. Savings are projected to reach US $2.3 billion by 2028 for ARVs alone.61

The Elton John AIDS Foundation was the fifth largest philanthropic funder of the HIV response in 2019, providing US $25.2 million in total.62 The foundation distributes its funding across high-, middle- and low-income countries, working in England, the southern states of the USA, Eastern Europe and Central Asia and Kenya (HIV self-testing), as well as providing funds that organisations across the world can apply to if they support or are led by people who use drugs or LGBT people. In 2020, it added a COVID-19 emergency fund to its portfolio.63

Case study: The funding crisis for key populations

Key populations and their partners (such as men who have sex with men and people who inject drugs) accounted for six out of ten new HIV infections in 201964, yet only 2% of available global resources in low- and middle-income countries are spent on HIV services that specifically support these groups.65

UNAIDS estimated that US $6.8 billion was needed to provide comprehensive HIV services for key populations (including PrEP) between 2016 and 2018 but only US $1.3 billion was provided – meaning there was a shortfall of 80%.66

The Global Fund provided 55% of the US $1.3 billion available between 2016 and 2018, PEPFAR provided 23%, private philanthropy 10%, domestic funding 7%. The Dutch Government provided 4%, with other donor governments and multilateral institutions contributing a 1%.67

Despite the clear need, supporting key populations is challenging for a number of reasons. High levels of stigma and discrimination create barriers and disincentives for key populations to access services, and drive people underground and to the margins of society. Organisations such as UNAIDS also remain almost completely reliant upon individual countries to provide data on these groups, and countries vary widely in how well they do this. 68

Evidence shows that targeting key populations is highly effective and efficient.69 70 71 To reflect this, and in the context of stagnating donor funding, donors have been establishing new funding frameworks and mechanisms to finance efforts that focus on key populations.

For example, since 2011, the UNAIDS Strategic Investment Framework has encouraged countries to prioritise their spending on groups most affected by HIV.72 Similarly, in 2016, PEPFAR launched a US $100 million Key Populations Investment Fund to expand HIV prevention and treatment access for key populations. The fund aims to identify, measure and tackle the factors driving stigma and discrimination that prevent access to tailored HIV services. The implementation of the fund took place from the financial year 2019/2020 so data on this is not yet available.73Targeting key populations is particularly challenging for a number of reasons. High levels of stigma and discrimination create barriers and disincentives for key populations to access services, and drive people underground and to the margins of society. Organisations such as UNAIDS also remain almost completely reliant upon individual countries to provide data on these groups, and countries vary widely in how well they do this. 74

While every region is failing to provide enough funding to support the HIV response for key populations, the situation is particularly bad in Latin America. Key populations accounted for half of all new HIV infections in 2018 but just 0.8% was spent on key population programming between 2016 and 2018. 75

How could funding be spent more effectively?

The rapid increase in spending on HIV treatment – in the era of ‘treatment as prevention’ – has led to a decline in funding for other prevention services. In 2019, US £5.3 billion of the US $18.6 billion (about 28%) of the funding available for the HIV response was spent on HIV prevention.76 This is in line with the 2016 Political Declaration on HIV and AIDS, in which member states committed to spend 25% of all spending on prevention.77 78

Who benefits from HIV prevention spending is an issue. Spending on HIV prevention programmes between 2016 and 2018 in low- and middle-income countries totalled US $11.5 billion, but only US $1.3 billion of this was invested in any type of HIV service for key populations, including prevention.79 This is despite key populations and their partners accounting for 62% of adult HIV infections in 2019.80Increasing funding for interventions aimed at key populations could also improve the efficiency of HIV financing. As mentioned above, the majority of funding for key populations comes from international donors. While these efforts help to fill the funding gap, they do not address the need for sustainable interventions driven by the domestic resources of affected countries.81 UNAIDS estimates that to get the HIV response back on track, US $ 9.5 billion should be spent on preventing HIV in 2025, almost double what was available in 2019, and that around half (47%) of these resources should be spent on supporting HIV prevention services for key populations.82

Human rights work plays a vital role in protecting populations most affected by HIV. Addressing social inequalities, such as law reform, providing access to justice, reducing stigma and discrimination and promoting gender equality, including tackling gender-based violence, not only addresses the rights violations millions of people experience, it also helps to make HIV programmes more effective, and ultimately holds the key to ending AIDS as a public health threat. UNAIDS estimates that funding to address what it describes as ‘social enablers’ should more than double from US $ 1.3 billion in 2019 to US $ 3.1 billion in 2025, equivalent to 11% of all funding for the HIV response. It estimates that failure to do this will result in an additional 1.7 million AIDS-related deaths and an additional 2.5 million new HIV infections between 2020 and 2030.83

In 2019, overall funding for HIV prevention research and development totalled US $1.14 billion, a fall from the US $1.17 billion spent in 2016. Just two donors, the US Government and the Gates Foundation provide 88% of overall funding in this area. 84

The future of funding for the HIV response

UNAIDS' 2021-2026 global AIDS strategy calls for a rapid increase in funding for HIV over the next few years to have a decisive impact on the epidemic and ensure the long-term sustainability of the HIV response. Not providing enough investment will lead to more people dying from an AIDS-related illness, more people contracting HIV and, ultimately, a higher financial cost to get the HIV response on track.85However, the impact of the COVID-19 pandemic and its economic fallout poses a significant threat to raising the investment needed, as donors and governments have re-channelled funds for HIV and other issues to fund COVID-19 responses.86 The next few years will be a crucial moment for the HIV response, with many warning that the hard-won progress on HIV may be reversed.87

UNAIDS argues that, rather than taking away from the HIV response to fund the COVID-19 response the dual epidemics should be addressed together, as the lessons learned through the HIV response, and the systems it has put in place across the world, can be used to respond effectively to COVID-19, while the unfolding response to the COVID-19 will undoubtedly yield lessons that can benefit both the HIV response as well as broader efforts to strengthen health systems.88

Even before COVID-19 surfaced, the stagnation of donor funding also posed a threat to reaching the amount needed to fully fund the HIV response in the coming years. Now, more than ever, there is a need to spend HIV funding on interventions and services that are cost-effective, efficient, and target the populations most in need.

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Last full review: 
25 May 2021
Next full review: 
25 May 2024
Last updated:
25 May 2021
Last full review:
25 May 2021
Next full review:
25 May 2024