PARIS — Even as HIV researchers buzzed about scientific advances and policymakers championed significant gains, this week's International AIDS Society Conference on HIV Science was dominated by concerns over global funding and worries that continued drops might undercut recent progress.
The most acute concerns center around the United States, the largest global donor to HIV care. If Congress adopts President Donald Trump's proposed 20 percent cuts in funding for HIV programs in ongoing budget negotiations, the world could see as many as 90,000 additional AIDS-related deaths starting next year, the Kaiser Family Foundation has estimated.
The loss of funding would further drain a diminishing pool of resources. A joint report from KFF and UNAIDS released ahead of the conference showed a 7 percent drop in global donor funding for HIV in 2016, plunging totals to a six-year low. New statistics from UNAIDS, while heralding the fact that 19.5 million HIV patients are now on life-saving antiretroviral therapy, also pointed to a $7 billion annual gap that could stymie efforts to reach the global target of putting 30 million people on treatment by 2020. Missing that goal, officials have said, would jeopardize the community's broader push to end the AIDS epidemic by 2030.
"[The] AIDS response [is] really built around the idea that the majority of the way we find people living with HIV is through antenatal clinics and then their partners."— Matthew Kavanagh, senior policy analyst at Health GAP
"We have a bunch of tools that really can move us forward in terms of epidemic control and I feel like the rug is being taken away from us in terms of the funding piece," said Linda-Gail Bekker, the current IAS president. "That, to me, is a tragedy."
While officials were hopeful U.S. funding levels could be maintained, thanks to ongoing bipartisan support for HIV programs on Capitol Hill, they still underscored just how tenuous the situation is. Even if funds are not cut, activists warned that the Trump administration's extension of the “global gag rule” — a ban on U.S. funds to international organizations that provide abortions or information about abortions — to include global HIV programs, could affect services and undermine the recent global gains.
All eyes on Washington
Among the 14 major donor HIV donors, the U.S. provides by far the largest support, disbursing $4.9 billion in 2016, which is why speculation about future U.S. funding received outsized attention at IAS.
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The U.S. was among the 11 donors whose funding fell from 2015, contributing to an overall drop from $7.5 billion in 2015 to $7 billion last year. According to Kaiser, disbursements in 2016 were at their lowest level since 2010. The majority of U.S. money is channeled through the bilateral President's Emergency Plan for AIDS Relief, PEPFAR.
While the U.S. decline from 2015 to 2016 was slight, at about 2 percent, Trump has proposed far more drastic cuts. His budget would chop approximately $2.5 billion in U.S. contributions.
Michel Sidibé, the executive director of UNAIDS, said he does not expect those cuts to make it through Congress. "I have met senators and congressmen from both sides," he said. "I can just say that it's bipartisan. People are seriously backing this program." Most experts expect Congress to deliver a budget that maintains current spending levels.
There is still some question, though, about where that funding will be channeled. PEPFAR currently operates in more than 30 countries, but in testimony before a Senate appropriations subcommittee in June, Secretary of State Rex Tillerson noted that the United States might restrict future spending to programs in 11 countries in order "to take those to conclusion." That has raised alarm among activists who worry that Tillerson was signaling plans to turn away from countries still struggling to control their epidemics.
Deborah Birx, who heads PEPFAR, said at IAS that the United States was committed to at least maintaining its current response.
"The U.S., from the beginning, has been a leader in funding the HIV response," she said. "We maintain that depth of commitment to the HIV/AIDS response and to continue to expand and accelerate in partnership with governments and communities. You can see by my being here that we're still deeply committed to responding to this pandemic."
The ‘global gag rule’
Ambassador Deborah Birx said Thursday the Trump administration supports PEPFAR — the United States global AIDS initiative — even though the White House has proposed to cut global AIDS spending by $1 billion.
The introduction of the expanded “global gag rule” has also prompted concerns about shifts in U.S. HIV funding, even if disbursement levels remain the same. When it has been introduced under previous Republican administrations, stretching back to President Ronald Reagan, it has only been applied to family planning aid.
The extension of the rule to nearly all U.S. global health assistance could force HIV programs that receive funding to split from maternal and child health providers that, for instance, provide information about abortions to their clients.
"Having to de-integrate those two things means that few pregnant women will get HIV tests and we'll not find them," said Matthew Kavanagh, a senior policy analyst for the HIV activism organization Health GAP. "Which is really scary in an AIDS response that's really built around the idea that the majority of the way we find people living with HIV is through antenatal clinics and then their partners."
Global health experts said it is still too early to gauge the full impact of the regulation. The U.S. government has started a six-month evaluation of the impact of the “global gag rule,” but even that might not offer a complete picture, said Alana Sharp, a policy associate with amfAR, the foundation for AIDS research. She said many government partners will still be implementing programs under old contracts during the evaluation, which do not fall under the regulation.
"We're concerned they're going to finish this review and say they found no impact when, in fact, it was just too short and too early to see impact," she said.
The risk of triage
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As officials wait to see what happens with U.S. funding, they issued urgent calls for other donors to scale up their contributions amid a recognition that there are not many more efficiencies that can be wrung from the response.
"We can certainly make more savings and be smarter," said François Dabis, who heads the French Agency for Research on AIDS and Viral Hepatitis. "But we cannot neglect the fact that to move from 19 to 20 million people on treatment and having biomedical services to 39 or 40 million soon, we will need more resources one way or another."
Instead of efficiencies, key officials have signaled that if cuts continue, the community might have to start thinking about triaging.
"From my point of view, we either move forward or we move backward," Bekker said. "With those kinds of cuts, I think we'll see ourselves moving backwards really rapidly. I think it will translate into people coming off treatment, people not starting treatment."
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