HIV funding is dwindling. Who will fill the gap?

MANILA — The world is off-track not just on HIV targets, but also on HIV financing. As the novel coronavirus continues to squeeze government budgets, experts note there are more questions and uncertainties on the future of HIV funding.

HIV funding declined in 2019, with donor government disbursements at $7.8 billion, according to the latest report by the Kaiser Family Foundation published this week during AIDS 2020. This represents a $200 million decrease in donor funding for HIV, comparable to 2008 levels.

The decline was mainly driven by declining U.S. disbursements, although the report also identified decreased disbursements from other donors such as Canada, Denmark, the European Commission, France, the Netherlands, and Sweden.

UNAIDS meanwhile estimates a shortfall of 30% in the overall amount needed to effectively respond to HIV in 2020.

Jen Kates, senior vice president and director of global health and HIV policy at KFF, told Devex in an email that before COVID-19 there were hopes that low- and middle-income countries could increase their HIV financing, and that several countries have done so, while external funding continues to play a role.

But COVID-19 has thrown off course these calculations.

“It is really uncertain how the funding gap can be closed. Moreover, it is likely to widen,” she said.

“If COVID-19 had not happened, I would have said that we were likely to see, at best, stable funding for a while that could be at risk of falling. Now, I think all bets are off,” she said, noting that it’s too early to know whether emergency funding from the U.S. and other donors can help fill gaps, or if affected governments would be able to respond to both COVID-19 and HIV.

The coronavirus pandemic has brought to the light the importance of strong health systems, and there is an expectation that even with governments all over the world experiencing a funding crunch, health investments would increase. But the reality in several countries shows that may not be the case. Nigeria, for instance, is proposing steep budget cuts of more than 40% to its health care budget.

“You would expect that in the case of a health crisis, that domestic spending on health would increase, but that's not necessarily the case,” said Amanda Glassman, executive vice president and senior fellow at the Center for Global Development.

“We still have a lot of Global Fund [to Fight AIDS, Tuberculosis and Malaria] and PEPFAR [U.S. President’s Emergency Plan for AIDS Relief] money out there, but the question is whether it's sufficient,” she said.

There have been moves by institutions such as the World Bank to get funding to countries with high levels of debt, and the Global Fund has made a percentage of its money flexible for countries to mitigate impacts of COVID-19. But there are still questions whether donors will honor their commitments to the Global Fund.

The Global Fund’s successful replenishment in 2019 was one of the few bright spots experts have noted when discussing HIV financing. There are also ongoing uncertainties on U.K. aid, the second largest government donor to the HIV response.

Glassman did highlight however that at present, some of the concerns have more to do on logistics and supply, with reports of drug stockouts and most health services focusing on COVID-19.

“I would put less emphasis on the funding gap and more sort of like, what do we have in place right now? And how can we respond? How can we protect expenditure from domestic budgets on the most cost-effective health interventions of which HIV AIDS intervention would be amongst though not all of them,” she said.

No new funding sources

Experts Devex has spoken to are not aware of any new initiatives that could inject additional resources to the global HIV response. But the HIV community should start working on a post-COVID-19 investment case for HIV programs, said José Zuniga, president and CEO at the International Association of Providers of AIDS Care. This should include communicating successes in the fight against HIV and the usefulness of long-established HIV infrastructure to the COVID-19 response.

“Communicating our successes, for example, that 25.4 million people were on HIV treatment in 2019, and large numbers of these people reside in Fast-Track Cities where a tremendous amount of work is being done to accelerate urban HIV responses, may prove to be an attractive ROI [return on investment] for some donors,” he said.

These could help show that a financial retrenchment at this time is “unthinkable,” he said.

An interest in global health security

Experts agree there will be a financing crunch, although Glassman said that overall funding for HIV/AIDS won’t go down so substantially vis a vis other health priorities.

“It's just because it's been 20 years of the international community investing in organizations and programs that do this. ... There's like a ton of HIV/AIDS researchers. There's a bunch of schools of public health [that] have received money to do HIV/AIDS research for years and years. So people really have this super specialty. So I just don't expect it to go away anytime soon or to be substantially reduced,” she said.

But there are concerns that COVID-19 would lead to competition for investments. Zuniga, for instance, thinks that governments may prioritize public health investments aimed at preventing and managing future pandemics in lieu of maintaining investments in HIV and other infectious diseases.

“This fiscal reality does not bode well for the global HIV response, and moreover it threatens the lives of countless men, women, and children whose only lifeline is bi-/multilateral development assistance and in-country investments in interventions that succeeded, for example, in decreasing AIDS-related mortality rates by 59% in 2019 — the lowest since 1993,” Zuniga said.

Glassman said it’s a question of whether growing interest in global health security includes existing infectious disease threats.

“I hope that there's not this huge pendulum swing to, you know, it's not health systems versus HIV/AIDS, it's health systems for HIV and AIDS, and for everything else that we need to do in the health sector,” Glassman said.