If donor government funding for HIV continues to fall, nearly two decades of progress against the disease will be in jeopardy, according to new research presented at the 22nd International AIDS Conference (AIDS 2018).
Using newly available data, a study from researchers at the Institute for Health Metrics and Evaluation and the Harvard TH Chan School of Public Health showed that cuts to development assistance for HIV could do serious harm in hard-hit countries, which continue to rely greatly on this aid.
“If donors falter in their support for HIV, the consequences could be devastating,” Linda-Gail Bekker, president of the International AIDS Society and international chair of AIDS 2018, said. “Smart investments are curbing the spread of HIV and saving both money and lives. Now is not the time to stall or pull back.”
A report issued by the Kaiser Family Foundation and UNAIDS found that eight of 14 donor governments reduced their spending on global HIV efforts in 2017. Overall, donor government funding for HIV increased from 2016 to 2017, following two years of declines. However, this increase was largely due to a shift in timing of US support, and is not expected to last.
A press briefing chaired by Jennifer Kates of Kaiser Family Foundation, highlighted the results of three new studies.
Summaries based on submitted abstract; updated data may be presented on site
Declines in development assistance for HIV threaten global progress
To date, there has been limited data on whether the downward trend in development assistance for HIV threatens global progress against the disease.
To address this and other research questions, a study presented by Annie Haakenstad of the Harvard TH Chan School of Public Health estimated HIV expenditures by source and function in 188 countries from 2000 to 2015. The results showed that of the $48bn spent on HIV in 2015, about 62% came from domestic spending by governments and about 30% came from development assistance. In countries with high HIV prevalence, however, nearly 80% of spending came from development assistance.
The study concluded that development assistance remains a major portion of spending on critical HIV prevention and treatment programmes, especially in the hardest-hit countries. The study team urged high-prevalence countries that rely on international aid to plan strategically to ensure that declines in external financing do not threaten progress towards an Aids-free generation.
Background: Development assistance provided by donors to combat HIV/AIDS in low- and middle-income countries decreased by 6.6% between 2012 and 2017, following a decade of 19.6% in annual growth. These decreases are concerning because little is known about the magnitude of domestic resources spent on HIV/AIDS across the globe and within each country. There is also little evidence about whether declines in funding threaten the reductions in HIV/AIDS incidence and mortality achieved since 2000. We addressed this critical knowledge gap by quantifying HIV/AIDS spending, identifying the source of these funds, and measuring HIV/AIDS spending on prevention, care and treatment, prevention of mother-to-child transmission of HIV/AIDS (PMTCT), and antiretroviral therapy (ART).
Methods: We collected and extracted data from five main sources: the AIDSinfo online database, Global Fund proposals, National AIDS Spending Assessments, National Health sub-Accounts, and the AIDS data hub. A spatiotemporal Gaussian process regression model was used to estimate HIV/AIDS expenditure by source and function from 2000 to 2015. All currencies were converted to 2017 purchasing power parity dollars.
Results: In 2015, global HIV/AIDS spending amounted to $48.1 ($45.7-$52.1) billion, a decrease of $800 million from 2013. Governments financed 62.2% (56.6%-66.7%) of total HIV/AIDS expenditure and out-of-pocket expenditure financed 5.6% (4.9%-6.3%). Development assistance for HIV/AIDS comprised 30.2% (27.8%-31.7%) of total spending in 2015. Among low-income countries, $0.11 in government health spending for HIV/AIDS is spent for each dollar of development assistance. In high prevalence countries, development assistance constituted 76.6% (73.6%-79.4%) of HIV/AIDS spending. Since 2000, expenditure on prevention has increased by 273% to 11.2 billion, while spending on treatment increased by 271% to 23.6 billion. In 2015, total expenditure on ART and PMTCT was $6.3 and $7.7 billion respectively.
Conclusions: Government resources played a substantial role in growth in global HIV/AIDS spending. Still, development assistance remains a major portion of spending on the prevention and treatment critical to millions living with HIV/AIDS. This makes these programs susceptible to future cuts in spending. High prevalence countries reliant on international assistance must plan strategically so that drops in external financing do not alter progress towards an AIDS-free generation.
M Moses, A Haakenstad, T Tao, A Chapin, J Dieleman
Domestic HIV spending has increased in low- and middle-income countries
A study presented by Deepak Mattur of UNAIDS provided new insight on trends in domestic HIV spending, based on an analysis of data from 112 low- and middle-income countries.
The study found that, overall, domestic public spending on HIV in these countries increased by 60% from 2006 to 2016. In low-income countries, it increased from $121m to $256m; in lower-middle income countries, from $231m to $980m; and in upper-middle income countries, from $2.4bn to about $6.9bn.
Almost all regions increased their domestic HIV resources. For example, in the Asia Pacific region, resources increased by 132%, and in Eastern and Southern Africa, resources increased by 57%. The lowest increase, 33%, was in Eastern Europe and Central Asia. The study also found that domestic public spending on HIV has a significant positive relationship with the GDP per capita of a country, coverage of antiretroviral therapy, and HIV prevalence.
The study concluded that sustained increases in domestic public spending will be critical for ending Aids as a global public health threat by 2030.
Abstract: Determinants and aggregate estimates of HIV domestic public spending in low-and-middle-income countries, 2006-2016
Session: Poster exhibition (Tuesday, 24 July, 10:00)
(Not yet available online)
HIV resources are generally well targeted for cost-effectiveness but can be optimised
A study presented by John Stover of Avenir Health in Glastonbury, US, investigated how well the current allocation of resources for HIV is optimized for cost effectiveness in 55 low- and middle-income countries that account for about 90% of all new infections.
The study found that cost effectiveness varies widely across countries and interventions. Antiretroviral treatment dominates cost per death and disability adjusted life years averted, and also ranks high in cost effectiveness for infections averted.
The most cost-effective prevention interventions were generally voluntary medical male circumcision, prevention of mother-to-child HIV transmission, outreach to sex workers and condom promotion. These programmes currently receive about 14% of direct intervention funding, which is about two-thirds of the need. The most cost-effective programmes are in East and Southern Africa, where HIV incidence is high and costs are generally low.
The authors concluded that resources for HIV prevention and treatment are generally targeted appropriately, but more focused allocation of resources could improve cost effectiveness by about a quarter. Resource allocations should be continually assessed because cost-effectiveness can change significantly as HIV incidence patterns change.
Background: Over $20 billion is spent annually on HIV programs in low- and middle-income countries. The allocation of resources by country and intervention depends on a mixture of need, funding sources, capacity, effectiveness, policy, politics and social factors. We investigated how well the current allocation is optimized for cost-effectiveness.
Methods: We applied an HIV simulation model, Goals, to 55 countries accounting for about 90% of all new infections to determine the cost per infection, death and DALY averted for each of 13 interventions. Units costs were based on Investment Cases for each country. The models were fit to surveillance and survey data and UNAIDS official estimates. Cost-effectiveness ratios were calculated by country and intervention by scaling up each intervention, one-at-a-time, over five years and recording the incremental costs, infections, deaths and DALYs compared to a counterfactual of no scale up of any interventions. The results comprise a database of total cost and cost-effectiveness measures for 716 country/intervention pairs.
Results: Cost-effectiveness varies widely across countries and interventions as shown in Figure 1 for cost per infection averted. Six percent of these combinations are cost savings because the total cost of the intervention is less than the savings generated due to treatment costs averted. ART dominates cost per death and DALY averted and also ranks high in cost-effectiveness for infections averted. The most cost-effective prevention interventions are generally VMMC, PMTCT, outreach to sex workers and condom promotion. These programs currently receive about 14% of direct intervention funding, which is about two-thirds of the need. The most cost-effective programs are in East and Southern Africa where incidence is high and costs are generally low. Currently almost 60% of all resources and 70% of donor resources are focused on ESA. About 15% of donor resources go to West and Central Africa where cost-effectiveness can be considerably worse.
Conclusions: Resources for HIV prevention and treatment are generally targeted appropriately but more focused allocation of resources could improve cost-effectiveness by about a quarter. Resource allocations should be continually assessed because cost-effectiveness can change significantly as incidence patterns change.
J Stover, Y Teng