By Lauren S. Campbell
In July of 2019, UNAIDS’s released its 2019 Global AIDS Update and admitted to the over ambitious aims of the 90-90-90 fast-track strategy.1 With new HIV infections rising in populations that have traditionally been neglected by the most prominent bi-lateral and multi-lateral funding strategies, the global AIDS community must quickly alter funding priorities to tackle the systemic injustices that continue to fuel the HIV/AIDS epidemic. Although the global AIDS response invests in multiple areas through a variety of different funding mechanisms, this report will focus on three funding topics: 1) donor government funding, 2) private philanthropic funding, and 3) Research and Development (R&D) funding. In order to reflect the multiplicity of stakeholder perspectives involved in setting AIDS funding priorities, this report incorporates analyses based on the perspective of health policy analysts, HIV/AIDS activists and advocates, and private financial donors – specifically, the Kaiser Family Foundation (KFF), the AIDS Vaccine Advocacy Coalition (AVAC), and the Funders Concerned About AIDS (FCAA), respectively. This report will outline the most notable findings of each organization’s most recent report on the current state of HIV/AIDS funding, and will include additional analyses on the cross-cutting investment trends that are likely to influence the future of HIV/AIDS funding.
After a complete organizational overhaul in 1991, the Kaiser Family Foundation (KFF) re-emerged as a non-profit institution that provides an open source of quality national and global health policy analysis.2 Since 2005, KFF has tracked yearly changes and trends in donor government funding for HIV in low- and middle-income countries (LMICs), and in its most recent report revealed that donor government funding outside of the United States has steadily declined for the past decade, thus resulting in over $1 billion lost.2,3 Over 90% of the loss can be attributed to a decrease in bi-lateral support by donor governments, however, as the bi-lateral funding channel continues to shrink, multi-lateral funding sources – such as the Global Fund and UNITAID – seem to be growing.3 Unfortunately, the slow growth of multi-lateral funding has yet to outpace the steady and consistent decline in bi-lateral funding, thus widening the resource gap of the global HIV/AIDS response.3 While declines in donor government contributions apart from the USA are cause for concern, the stability of the United States’ contributions to the HIV/AIDS global response has prevented severe declines in the global availability of donor government funds. Since the early 2000s, the US has remained the most prominent leader in the global HIV/AIDS response. However, the future of the United States’ continued commitment to the AIDS cause remains highly uncertain.3
Historically, the US has led the mobilization of international resources for HIV/AIDS through a combination of multilateral funding channels and the President’s Emergency Plan for AIDS Relief (PEPFAR). Since its enactment in 2003, PEPFAR has been essential to dampening the epidemic in many LMICs – however, PEPFAR funding has also contributed to the chronic underinvestment in the health and protection of many vulnerable populations and communities.4 Due to its conservative and evangelical origins, PEPFAR funding has often been contingent on the promotion of anti-prostitution, anti-drug, and/or abstinence only policies.4 The exclusionary conditions of PEPFAR have deepened stigma and discrimination against key HIV/AIDS populations in many LMICs, and although PEPFAR’s funding priorities are flexible, the growing wave of conservativism and isolationism in the United States foreshadows a stricter enforcement of exclusionary criteria. The first manifestation of which being the expansion of the Mexico City Policy (also known as the Global Gag Rule) to apply to the United States’ global health agenda at large, therefore expanding the policy’s reach and implicating many organizations that currently receive PEPFAR funding.5 Furthermore, the current US administration has proposed significant cuts to PEPFAR and weaker financial commitments to the Global Fund. Although the US Congress has, so far, denied cuts to the AIDS budget, the potential for additional US funding seems highly unlikely. While the fight against HIV/AIDS should be a unified global response, the steady declines in non-US donor government contributions leaves the funding of the global AIDS response increasingly dependent on the political will of the United States.
Similar to the growing dependence on the United States as the primary public sector donor, the philanthropic sector has also grown to heavily rely on a few very large private donors. In 1987, a group of HIV/AIDS grant makers and organizers formed Funders Concerned About AIDS (FCAA) to help mobilize philanthropic participation in the global fight against HIV/AIDS.6 In addition to educating stakeholders, the FCAA has also tracked changes in philanthropic donations for the past 16 years.6 The most recent FCAA report revealed a 5% drop in funding due to a decrease in donations by just 7 of the 427 philanthropic donors reported to have funded HIV/AIDS-related activities.7 This heavy reliance on a few large donors is further illustrated by the fact that the top 2 donors – the Bill and Melinda Gates Foundation (BMGF) and Gilead Sciences – make up 59% of the total amount of philanthropic funding disbursed (with BMGF contributing 36% and Gilead contributing 23%).7 Although the BMGF has exponentially increased global philanthropic funding since its creation in 2000, the foundation’s growing monopoly over the philanthropic HIV/AIDS sector has left programming outside of the foundation’s research-based agenda highly neglected.6 The FCAA revealed that despite communities being at the forefront of the global HIV/AIDS response, research funding continues to supersede advocacy and social services funding by $95 million and $122 million respectively.7
In addition to the increased influence of large philanthropic foundations, the popularization of “corporate social responsibility” within private industry has redefined the notion of the traditional not-for-profit philanthropic organization. As corporations rapidly enter the realm of HIV philanthropy as a means to boost brand image and garner public trust, the commercial interests of large industries grow increasingly intertwined with the global HIV/AIDS agenda. This change in the traditional philanthropic donor profile is particularly concerning as the pharmaceutical industry creates well-funded corporate-based philanthropies designed to advance pharmaceutical interests in a traditionally equity-driven environment. In addition to the bad faith conflation of social responsibility with PR, the profit-driven interests of pharmaceutical corporations often perpetuate a failed and unjust HIV strategy that prioritizes financial gain over social equity. Evidence of this exploitative behavior is illustrated by the FCAA finding that, in 2017, more than half of all country-level philanthropic funds for HIV/AIDS went to high-income countries, while funding for LMIC dropped by 19%.7 Although large funding commitments to HIV/AIDS are needed to sustain programming and research activities, the presence of profiteering actors within the philanthropic sector allows self-interested financiers to hide behind the guise of altruism as they unfairly determine the global availability of innovative HIV/AIDS treatment and prevention options.
Although the influence of large donors can be felt at every level of programming, research and development (R&D) consistently ranks as one of the most well-funded areas of the HIV/AIDS response, in terms of both private and public investments. Founded in 1995 by HIV activists, the AIDS Vaccine Advocacy Coalition (AVAC) aims to accelerate vaccine development through the biomedical promotion of HIV treatment and care.8 In AVAC’s most recent R&D resource tracking report, the organization revealed that HIV R&D funding increased for the first time in five years – totaling $1.14 billion in investments.9 The top funded prevention strategies were vaccines, microbicides, and PreP – with vaccines taking up ~75% of the total R&D budget.9 Given that AVAC follows both public and private R&D funding channels, the findings in the AVAC report mirror many of the conclusions from KFF’s Donor Government Funding for HIV in Low- and Middle-Income Countries 2018 Report and the FCAA’s Philanthropic Support To Address HIV/AIDS 2017 Report.3,7 According to AVAC, the top two funders of HIV R&D are the United States government and BMGF. Together, the contributions from the US and BMGF account for 86% of total R&D funding (with the US public sector contributing 73% and BMGF contributing 13%). By heavily financing the HIV/AIDS response at the earliest stages of R&D, large donors are able to influence the trajectory of scientific discovery, and thereby pre-determine HIV/AIDS strategic priorities. Additionally, the AVAC report also revealed that most R&D funds are allocated for the preclinical and clinical phases of development, with very little investment directed toward the implementation research required for effective program roll-out.9 While the biomedical approach to HIV has the dual benefit of acting as a form of HIV treatment and prevention, advances in scientific innovation will remain inconsequential if the social barriers that currently prevent access to the most basic forms of care remain unchanged.
Diving deeper into the financial influences driving the biomedicalization of the HIV/AIDS response, AVAC’s report also indicates that while the number of R&D donors has stagnated, the proportion of private sector investments has increased.9 Given the high level of scientific innovation and market interest in HIV R&D, increased private sector involvement likely stems from the pharmaceutical industry’s heavily vested interest in monopolizing the HIV treatment market. As individual entities, pharmaceutical corporations can undermine equity by prioritizing the demands of wealthy consumers; however, an even greater threat to access looms as large private foundations deepen partnerships with the pharmaceutical industry. In 2002, BMGF purchased $205 million in stock from nine pharmaceutical giants, such as Merck & Co., Pfizer, and Johnson and Johnson, and in 2011 appointed a former pharmaceutical executive as the president of the BMGF Global Health Program.10,11 Although the impact of the alliance between BMGF and Big Pharma is difficult to measure, the sheer number of R&D grants directly and indirectly linked to Big Pharma raises concern over the potential leveraging of HIV funds as a way to impose country compliance with strict intellectual property laws. This is of particular concern in developing countries where access to innovation is barred by profit-driven patent owners that completely disregard social equity as a factor in drug pricing.
Since the beginning of the global HIV response in the late 1990s, the accumulation of trade-offs attached to many bi-lateral and multi-lateral funding channels has resulted in a disproportionate concentration of HIV risk in the most under-resourced and vulnerable communities. This concentration of risk now fuels the growing HIV epidemic in many LMICs and although inclusive community-based approaches are now at the forefront of the global HIV/AIDS conversation, the AIDS funding landscape must undergo dramatic democratization if the global HIV response is to truly pursue more equitable aims. Although significant investments from public and private funders are still needed to support the global HIV response, the health and human rights of entire communities should not be predicated on the self-interest of a few large HIV/AIDS donors. Activists, advocates, and civil society actors must continue to highlight the true needs of communities and must openly challenge the motivations and actions of large donors who claim to support the global HIV/AIDS fight.
- (2019). Communities at the Centre: Global AIDS Update 2019. Retrieved from https://www.unaids.org/sites/default/files/media_asset/2019-global-AIDS-update_en.pdf
- Kaiser Family Foundation. (2019). About Us. Retrieved from https://www.kff.org/about-us/
- Kaiser Family Foundation. (2019, July). Donor Government Funding for HIV in Low- and Middle-Income Countries in 2018. Retrieved from https://www.kff.org/global-health-policy/report/donor-government-funding-for-hiv-in-low-and-middle-income-countries-in-2018/
- Moss, K and Kates, J. (2019, January 29). PEPFAR Reauthorization: Side-by-Side of Legislation Over Time. Retrieved from https://www.kff.org/global-health-policy/issue-brief/pepfar-reauthorization-side-by-side-of-existing-and-proposed-legislation/
- Kaiser Family Foundation. (2019, June 6). Expanded Mexico City Policy Hindering Access To Health Care For Some Women in Africa, Asia, Report Says. Retrieved from https://www.kff.org/news-summary/expanded-mexico-city-policy-hindering-access-to-health-care-for-some-women-in-africa-asia-report-says/
- Funders Concerned About AIDS. (2019). History. Retrieved from https://www.fcaaids.org/about-us/history/
- Funders Concerned About AIDS. (2018, December). Philanthropic Support to Address HIV/AIDS in 2017. Retrieved from https://www.fcaaids.org/wp-content/uploads/2018/11/FCAA_2017RT_FINsingles.pdf
- AIDS Vaccine Coalition. (2019). Our Story. Retrieved from https://www.avac.org/our-story
- AIDS Vaccine Coalition. (2019, July). 2018 HIV Prevention Research and Development Investments: Investing to End the Epidemic. Retrieved from http://www.hivresourcetracking.org/wp-content/uploads/2019/07/rt_2018.pdf
- CDC National Prevention Information Network. (2002, May 17). Bill Gates Charity Buys Stakes in Drug Makers. Retrieved from https://www.thebody.com/article/tag-10-year-1995
- New, W. (2011, September 11). People: Pharma Executive TO Head Gates’ Global Health Program. Retrieved from https://www.ip-watch.org/2011/09/14/pharma-executive-to-head-gates-global-health-program/