AIDS funding is in crisis. Who will step up?

Medicines might have saved the lives of Elizabeth Mebele’s two sisters, who died of AIDS complications within the last five years. As Mebele marched outside last week’s International AIDS Conference in Durban, South Africa, she recounted how they were turned away from care. “There was no treatment, that’s why they passed away,” Mebele said. “Things are not reaching the right people.”

Access to lifesaving antiretroviral therapy is exactly what protestors demanded 16 years earlier at the same IAC, also held in Durban. Their call, echoed by former South African President Nelson Mandela in his closing address, marked a turning point. Soon after, global drug prices began to fall and treatment became more widely available.

Now, progress may be reversing again. Scientists say the tools are available to end the AIDS epidemic. But public health interventions are running out of money. And even as officials talk about the approaching end of a pandemic that has killed more than 35 million people, the goal of eradicating AIDS is looking ever further away.

Funding has dropped before, but this time seems different, said Mike Podmore, the director of STOPAIDS. Global fatigue has set in after nearly two decades of funding the AIDS response. Donors are pushing middle-income countries to take on a greater share of funding their HIV/AIDS programs, but health budgets and systems are already stretched. Some costs can be cut by delivering services more efficiently, though that approach is unlikely to bring about the end of AIDS.

All this added up means the indefinite continuation of the world’s deadliest epidemic.

“I think it’s really a massive crisis point right now,” Podmore told Devex. “Things have changed and moved on. And we could find ourselves a couple of years from now with infections and death skyrocketing.”

The end of AIDS?

The Sustainable Development Goals aim to end the AIDS epidemic by 2030, but in a recent report, UNAIDS estimated that reaching that target would require $26.2 billion in funding for low- and middle-income countries by 2020 — estimated to be the peak year of investment. That is $7 billion more than was available in 2014. Donors, meanwhile, reduced their investments by more than $1 billion last year as compared with 2014, according to a recent joint report from the Kaiser Family Foundation and UNAIDS.

Donors are encouraging middle-income countries to take more responsibility for their own epidemics. But officials in many of those countries say they can’t. According to the Kaiser and UNAIDS report, domestic spending already made up 57 percent of total resources in 2015, or $10.9 billion.

“We will be able to continue to treat people,” said Brian Honermann, the deputy director of policy for amfAR, which helps guide HIV research. “But it will cost more and it will cost more in perpetuity. And it will put a greater and greater strain on healthcare systems that are already under strain.”

The situation is particularly galling to international activists because of the advances that have been made. More than 17 million people are now on ART, which can both deliver HIV patients a natural life span and make it virtually impossible for them to transmit the disease.

At the same time, there is evidence to support the significant preventive capacities of interventions. Male circumcision has been shown to reduce transmission of HIV by about two-thirds. And pre-exposure prophylaxis — the distribution of antiretroviral drugs to people who are not infected, but are at heightened risk of acquiring the disease — has been demonstrated to be highly effective in preventing transmission. These follow alongside condom usage, needle exchange and other efforts to encourage people to reduce the risk of transmission.

“We have what we need to ensure people are healthy,” said Matthew Kavanagh, the senior policy analyst for Health Global Access Project, a global advocacy organization. “It’s possible when it’s funded. But that’s not the track we’re on.”

Will domestic resources fill the gaps?

The responsibility for funding is increasingly being directed to the countries with some of the world’s highest epidemics. The UNAIDS report listing investments needed to actually end the epidemic by 2030, calls for significant increases in domestic spending.

According to the report, in order to end AIDS by 2030, lower-middle-income countries need to increase investments from $4.3 billion in 2014 to a peak of $8.2 billion in 2020. For upper-middle-income countries, the apex comes at $11.3 billion in 2017, up from $9.4 billion in 2014.

Many experts see the call for any significant new investments as unrealistic.

“There’s simply no political way in hell that countries will spend major significant proportions of their total income on AIDS,” said Ben Plumley, chief executive officer of Pangaea Global AIDS, which connects people to HIV services. He said many of the projections are based on economic growth that was stymied by the 2008 recession. “Having a global strategy is critical, but it’s got to be rooted in evidence. It’s got to be rooted in reality.”

Officials in epidemic countries told Devex that even as they are being badgered to put in more money, their existing contributions are being overlooked. Dr. Nduku Kilonzo, the director of Kenya’s National AIDS Control Council, said her government puts significant resources into the systems that allow for the delivery of HIV services — including paying salaries for health workers and maintaining health centers. Those expenses are not usually included when international agencies tally domestic contributions.

As a result, the Kenyan government is reframing how it presents the money it spends on HIV. Those systemic costs will now be grouped in AIDS spending assessments, she said.

“It is really not realistic to have a conversation about HIV and the expenditure and the contribution of different players when those significant primary costs that drive treatments are not part of the conversation,” Kilonzo said.

No new money

Absent new funding, discussions at the IAC centered on ways to save money by making services more efficient. A number of different ideas were floated, from increasing the amount of ART given to patients, so they do not need to visit clinics as often, to redistributing health workers from oversaturated urban areas to more sparsely populated communities.

Local and international officials said they were eager to save money where they could but doubted whether efficiency could bridge funding gaps. “The bulk of our members believe that they’re pretty efficient already,” said José Zuniga, the president of the International Association of Providers of AIDS Care.

Which leaves the unresolved question: Where is the money going to come from? The answer is unclear, even though the effect of not doing so is.

Andrew Green reported from Durban on a fellowship with the International Reporting Project.

Access to Medicines is an online conversation to explore work being done to guarantee access to lifesaving medicines, where solutions are still needed. Join us as we look toward the future, tagging #access2meds and @Devex to share your thoughts.