The July 2015 report by The Kaiser Family Foundation (KFF) and UNAIDS on Financing the Response to HIV in Low-and Middle-Income Countries, comes out at a critical time for the global response to the epidemic. With publication of the UNAIDS-Lancet Commission Report, the START trial results, the Vancouver Consensus, and the UNAIDS agenda to “end AIDS by 2030,” this financial report has the potential to provide a foundation for serious activism demanding increased funding where it is needed. There now exists empirical evidence that demonstrates just how much global AIDS funding exists, and how much more there needs to be. The key findings from the Kaiser-UNAIDS report neatly display financial contributions from the 14 major donor countries, and this commentary aims to interpret those findings in the context of the global AIDS epidemic.
The first and most troublesome finding from the Kaiser-UNAIDS report is that donor government disbursements only increased 1% overall from 2013 to 2014, totaling US$8.6 billion, after accounting for inflation and exchange rates. This overall increase, both bilaterally and to the Global Fund, would not have been possible without the specific contribution from the United Kingdom. UNAIDS projects that in order to end AIDS by 2030, total global contributions must be between US$22 and US$24 billion. It is extremely problematic that not only are we in need of almost three times the current disbursement amount, but that the incremental increase of 1% a year is minimal and will never allow us to reach a level that would sustain the current response to the epidemic, let alone an amount that might make possible recent promises concerning “the end of AIDS”. This finding demonstrates the immediate need for major increases in funding and serious recommitments from all donor countries.
While most government donations continue to be bilateral, it is important to note that overall contributions to the Global Fund have increased and bilateral assistance has declined. Six donors now provide the majority of their disbursements for HIV through the Global Fund, indicating that the Fund has become a major channel of international HIV support, especially for a subset of donors. Bilateral donations allow donor governments to have control over what their money is used for and where it is targeted. Since this form of financing takes control away from the countries receiving the donations (and away from the people who know their country’s epidemic best), it may be a good sign that bilateral funding is decreasing. However, when considering the six countries who provided the greatest share of their HIV financing to the Global Fund (see Figure 3 in the Kaiser-UNAIDS report), it is important to note that these countries also provided the least funding to HIV when standardized by the size of their economies (see Figure 6). While moving away from bilateral to multilateral funding may put more control in the hands of recipient countries’, an increase in funding to the Global Fund may be a result of donor governments distancing themselves from the efforts they are putting money towards. What’s more, only five of the 14 donor countries increased their donations from 2013; seven of the 14 decreased their contributions and two (including the USA) remained stagnant. Both the declines in funding and the current trends regarding financing to the Global Fund may be signs that the “AIDS fatigue” that has plagued international HIV and AIDS efforts for much of the current decade is not going away, despite optimistic slogans around “ending AIDS by 2030.”
A significant portion of the report is dedicated to “fair share” analysis. This section starts by posing a series of questions that should be considered when determining what constitutes a government’s “fair share” of international HIV assistance, as they have methodological implications. In light of these questions, three methods of assessing fair share are provided. The first two methods objectively display the highest and lowest donors in terms of funding and resources disbursed for HIV. The third method demonstrates how much a country contributes in government disbursements in relation to the size of its economy (measured per US$1 million GDP). Denmark tops this list by contributing nearly $500 per US$1 million GDP, whereas the UK and the USA spend approximately $100 and $170 less, respectively, per US$1 million GDP than Denmark does, and the other disbursement efforts decline rapidly from there. When standardizing contributions by the size of countries’ economies, it becomes apparent which countries are significantly contributing to international HIV and AIDS efforts and which countries can afford to contribute much more. Japan, for example, represents 6% of the world GDP but ranks second to last in international disbursement, and countries of a similar position are Germany, France, Italy, Canada, and Australia. When compared to Denmark, even the largest donors – the USA and the UK – can afford to contribute more based on their GDP.
Further, it is prudent to clarify that this Kaiser-UNAIDS report only reflects the trends in public contributions from these specific 14 donor countries. It does not represent a rigorous review of other nations’ donations or, more significantly, of the international donations of the private sector. Future investigation into the relationship between private and public funds would provide a more comprehensive understanding of the current financial state of HIV funding. For example, does this trend of minimal increase and flat-lining of public funding carry over into the private sector, suggesting a bleak picture for HIV funding as a whole? Or has there been an increase of private sector donations, therefore causing a loose justification for governments to decrease their individual public donations? Does the absence of these public funds create a vacuum where the private sector, with possibly more commercial or even ideological interests, could insert itself? These questions are important points of departure for future financial research and investigation.
Zooming out from the specific findings of the report, now that the HIV and AIDS advocacy community has access to these numbers and its implications, what do we do with them? What’s next? This report serves as a potential resource for activism as an empirical data set to support both claims and advocacy for more funding and from the appropriate funders, and this fact should not be undervalued. The report cannot be dismissed, because it comes at a critical moment where the HIV establishment is calling for the end of AIDS by 2030. The UNAIDS-Lancet Commission and the Vancouver Consensus both call for sweeping mobilization and renovation of international HIV responses, including a renewed commitment to human rights and confronting the structural forces that perpetuate the HIV epidemic. None of this can be achieved without sufficient and appropriate funding, and while these publications champion a laudable response that is fixated on ending the human suffering caused by AIDS, they do so without robust financial plans. The Kaiser-UNAIDS report highlights these glaring disparities between intent and practice: the gap between the goals set and acquiring the money necessary to achieve them. There is simply not enough money being invested in HIV. We require more.
If the global HIV response is unable to achieve stronger financial commitments, then cheaper, less expensive interventions must be sought. This would mean to properly address the pharmaceutical patents that prevent the increase of the number of patients on treatment, especially in the case of high-priced patented antiretrovirals (ARVs). After 20 years of both the TRIPS agreement and the availability of HAART there is a wealth of evidence showing that the increase of patients on treatment is directly related to the decrease of ARV prices.
Therefore, in this scenario, we would require more strategies to foster the availability of generic drugs, even for new generations of HIV treatments. Such efforts are important and needed, but as this report shows, impartially, at least six countries out of the 14 can simply afford to give more money given the size of their economies. Advocates and civil society groups must take advantage of this data to illustrate and reiterate this point to the top donor governments: your efforts are strong, but they are not strong enough. Now is the moment for civil society to step forward, using this report as a tool to strengthen our arguments. We now have the evidence that more funding is needed to achieve the goals that have been set for 2030. The next step is to advocate.