In the fight to end the HIV and AIDS epidemic, a small window of opportunity is opening. Efforts have almost reached the half-way point for ending the disease: the number of those in treatment, 1.7 million people, is on track to surpass the number of new annual infections, about 2 million, by next year. The time is therefore ripe for reassessing what works, what doesn't, and where financing will come from to get and stay ahead of HIV and AIDS.
Devex spoke with Erin Hohlfelder, head of global health policy at the ONE Campaign about the most promising financing tools on the HIV and AIDS front, how the indicators for the Sustainable Development Goals and new financing trends can shape the donor landscape, and how organizations are adapting to the rapidly shifting need to reach the most marginalized populations.
Here are some highlights from that conversation:
What’s changed in the funding landscape for efforts against AIDS since 2000? What are the new challenges in battling donor complacency?
We know infectious diseases don’t wait around for opportune political moments, they will continue to spread if they’re not effectively targeted. And that’s the same for HIV, malaria, and even we saw in cases like Ebola. If donors get complacent or delay funding disbursements, we allow situations to get out of control and ultimately cost us a lot more money to fix than if we had addressed them head on.
One way to do this is to look at the health budgets not just for donor countries, but recipient countries as well. We then [compare that to] development assistance writ large, and in our report we look at African country spending on health writ large as well. We don’t think it’s right to just fight for AIDS funding or just fight for malaria funding if it robs Peter to pay Paul. We want to tackle disease intervention in a holistic way.
Why is 2016 an important year for global HIV and AIDS efforts?
Barring any surprises, the new SDG indicators will include an indicator focused on ending AIDS as an epidemic. It’s good to have that ambition lodged in a technical document, but I think we need to find ways to make that more than just lofty ambition on a piece of paper. It’s up to scientists, technical experts and advocates to game out other scenarios about the moment of jeopardy that we’re in.
There are three big moments in 2016. In June or July, there will be a U.N. special session on AIDS. The last time this happened they produced a bold new set of targets, which really helped drive advocacy.
Another is the return of the AIDS conference to Durban, South Africa, in July. The AIDS conference is always a big moment to come together to assess, but the last time it was in Durban it was such a pivotal point for the movement. You had South Africans fighting their own government for treatment access, you had Nelson Mandela, so I think you’ll see a revival of that spirit to talk about the pivots on the continent.
Then, the Global Fund [to Fight AIDS, Tuberculosis and Malaria] replenishment itself. The timing is still up in the air depending on who is hosting the conference, but we think if that happens, say in the fall, it will be a huge capstone moment, both as a test for how serious donors are about this fight, but also a way of round out the year, and set us on a fresh course with new resources.
Is the Global Fund’s marked increase in donor funding in the last decade a sign that the multilateral model is working well in the fight to end the AIDS epidemic? How do you make a case for emerging economies and smaller donors to invest in big multilaterals like the Global Fund?
We see such tightness in so many countries’ foreign aid budgets that at the end of the day, what donors most care about is getting clear, measurable results from their investments. I think the Global Fund has really given us one of the most impactful tools we have and I think donors appreciate that it’s evolving as a mechanism. It’s getting smarter and more effective in how it does business.
Just to give an example, in the last year or two the Global Fund has been reforming some of its procurement policies, and just in doing that saved hundreds of millions of dollars. Donors see that and respond to that. They see their money isn’t being taken for granted; it’s being spent in increasingly more effective ways, and increasingly targeted at the most marginalized and vulnerable populations.
Also, multilateral actors are more appealing for smaller donors. Let’s say smaller European countries, they have in some cases smaller bilateral efforts, but if they’re not putting a ton of resources in, it might be hard to see the kind of large-scale impact that they can see and be a part of. Donors coming together for the Global Fund both gives smaller donors more bang for their buck but also allows them to be a part of this much greater collective success.
As donor focus increasingly shifts to fragile states, what are the risks for HIV and AIDS efforts in low- and middle-income countries?
This is the ongoing political tension we’re facing, getting this balance right. On the one hand … the world needs more focus on the [least developed countries] and fragile states who have received less [official development assistance] in recent years, but … we’re really conscious that we don’t want the pendulum to swing too far the other way.
This is particularly true for a disease like HIV, where you see growing rates in middle-income countries. Donors and partners have to strike the right balance, and have to be creative in how they’re not just funding but implementing programs so that they are emphasizing the highest-burden areas and making sure they’re also reaching the LDCs and the most vulnerable populations, which are not always the same thing. It takes not only increased investment, but tailored thinking: If we’re going to give less to middle-income countries, how are we going to make sure we still care for the most marginalized and vulnerable populations in those countries that are at increasing risk and need of services?
Look at Russia and the Ukraine, who have skyrocketing HIV infections among the most vulnerable people. None of us are content to sit back and abandon those populations just because they happen to live in relatively wealthier countries. This is going to be the next real challenge, not just for donors, but for implementers like PEPFAR and the Global Fund to figure out how to strike this balance effectively.
What are the models for success in domestic resource mobilization for AIDS programs in-country?
I think there are countries like Botswana and Rwanda that have done a good job increasingly paying for more health services themselves and putting their own skin in the game, and certainly, a country like South Africa now funds something like 80 percent of all [antiretrovirals] in its population with its own domestic resources. But I wouldn’t necessarily feel comfortable yet saying that’s a success story.
South Africa has been the case study for how transitions [from lower- to middle-income country], when they’re rushed, actually lead to backsliding or gaps in service or coverage. [We haven’t] really nailed that equation properly yet, where we encourage countries to really step up and do more, but are also providing ongoing donor and technical assistance and backstopping to make sure nobody’s falling through the cracks.
For years the Global Fund has had a tacit co-financing policy in place, but they never really were able to measure and enforce that in a meaningful way. It’s only been in the last two years, that they’ve revamped their co-financing strategies with countries and started to acquire greater amounts of domestic funding. They’re now starting to make this policy have some teeth and feel real, and we’re seeing an uptick in country investment as a result.
I fully anticipate as we come into this [Global Fund] replenishment year in 2016 that the narrative around what countries are paying is going to be increasingly important. Both for countries weaning themselves off of donor dependence, but also for sending an important message to the donor, to say that their resources are in many ways increasingly catalytic. Rather than being “endless,” donor funds can get countries onto a more self-sustained trajectory for financing.
What are the most promising new financing tools?
There’s both large- and small-scale efforts that are interesting. On the donor side, the financial transaction tax and the extent to which that can be replicated across Europe could be a really interesting new way of generating funds, not just for the Global Fund, but for other health and development crises as well. We’ll be watching that with great interest.
On a smaller scale, we’ve been looking at development impact bonds — DIBS — and we’ve seen some success with those in malaria outcomes and pilot HIV outcomes. We could be doing more to encourage replication of those — it won’t be a be-all, end-all solution, but could be an interesting way of getting clear, measurable results, particularly for [harder-to-reach] populations.
On the domestic side some countries putting in new levies and taxation policies, whether an airline levy, or a tax on beer and tobacco, there’s lots of new ways these countries can be generating new revenue streams to fight some of the biggest challenges that impact their own citizens.
For us, it’s the blend of innovation from donors and from countries themselves that’s really going to help to fill this wide funding gap that we’re in.
How are the more traditional advocacy and bilateral development organizations focused on HIV and AIDS innovating and updating their approach?
PEPFAR is undergoing a huge overhaul under Ambassador [Deborah] Birx in how it delivers funding. She’s made it very clear that she wants data to drive decision-making in a new and more focused way, and the increased focus you’re seeing from her and also Mark Dybul at the Global Fund on adolescent girls and young women is really encouraging. Focusing on women and girls is following the data and the science to say, this is where we’re falling behind. AIDS is now the leading cause of death of young women in Africa.
You’re going to see less of an overall evolution of programs like PEPFAR, but more in terms of how and where they’re focusing their limited resources. You’ll see a lot more in biomedical prevention, treatment as prevention. The START trial that came out recently reinforced how important early treatment initiation is, not just so the patient can stay healthy but so they’re less likely to infect others.
You’ll see a lot more data-driven innovation around sensitively targeting marginalized populations — men who have sex with men, people who inject drugs, transgender people, sex workers — making sure we know where they are, and better understand how to reach them.
Where is there the most potential for partnerships on the HIV and AIDS front?
Overall philanthropic and private sector giving to AIDS is at an all-time low, down from 2007, so one space where there’s a need for engagement is the private sector.
Sometimes I think we include a private sector voice on a panel and it’s like we’ve ticked a box for private sector engagement, but it can and should go so much deeper than that. There’s a lot corporations can do off-budget to make sure AIDS and other health investments are being maximized. Coke partnered with Yale and RED on the Last Mile partnership to improve supply chains of commodities and treatment, for example. It’s partnerships like that that can and should be replicated more frequently. Companies who know the communities, who know the systems in which they’re working.