UNAIDS estimates that at least US$26.2 billion will be needed annually by 2020 to implement an optimally effective AIDS response5. In 2015, total HIV investments amounted to US$19.0 billion, and no meaningful increase in total resources for AIDS occurred within the past three years, raising concerns about our ability to sustain the gains we have made1. These trends leave us well short of what we need to drive further progress in reducing new HIV infections and AIDS-related deaths.
Our community faces important challenges in working to mobilize essential new funding. The range of global health and development priorities is proliferating, as reflected in the nearly 200 targets of the Sustainable Development Goals. It will require nimble, steady advocacy to both make the case for new resources for AIDS and show how these investments improve multiple development priorities.
Activism by scientists, clients, healthcare workers and community members has sustained the AIDS response. But in traditional donor countries, the grassroots energy that helped propel funding increases has dissipated. If we hope to save the next generation from the health threats posed by the epidemic, we must get back to basics, uniting in an urgent effort to remind decision-makers that HIV isn’t over, and that pulling out now risks losing all the gains we have made and effectively wasting the unprecedented resources that have already been spent.
Strengthening sources of predictable and sustainable financing
For several years, the most reliable funding for HIV prevention and treatment programmes has come from the Global Fund and the US President’s Emergency Plan for AIDS Relief (PEPFAR). Funding pillars for HIV scientific research have included the US National Institutes of Health and the Bill & Melinda Gates Foundation. Moving forward, ensuring the continued strength of these funding sources will be pivotal to hopes for major progress on AIDS. The successful three-year replenishment of the Global Fund in 2016 offers encouragement that this essential funding vehicle will remain for the foreseeable future.
However, these seemingly solid sources of AIDS funding also confront potential threats to their viability. Many European governments have curtailed global health and development spending to accommodate new spending for other priorities. And in the US, historically the leading provider of AIDS financing, anticipated deficit reduction efforts and other factors could place sharp downward pressure on funding for the global HIV response. Strong, smart and sustained advocacy will be needed to meet these challenges.
Additionally, we need to push back against the growing notion that national income categories alone should determine eligibility for international support. Many of the key populations most heavily affected by HIV live in middle-income countries. Although some middle-income countries are addressing the HIV-related needs of key populations, many more are not. People, not national borders, should be the touchstone for how AIDS resources are allocated.
Increasing domestic investments in AIDS
Even as overall spending on AIDS has begun to decline over the past two to three years, domestic spending on AIDS has continued to increase as more and more countries are allocating public financing towards HIV prevention, care and treatment programmes. Yet while domestic spending has been a recent bright spot, most countries are still spending far too little, especially on primary prevention.
“We very much appreciate the efforts by the government and other partners to make antiretroviral therapy available throughout our country. However, third-line regimens remain unavailable. We urgently need to make these available, as we already have patients who are failing on second-line regimens. Although viral load monitoring is now less costly than it was, it remains a luxury for some patients.”
Dr. Hermine Meli, IAS Member
Healthcare worker, Cameroon
Analyses indicate most countries have yet to dedicate public sector funds to the AIDS response to a degree that corresponds with their economic potential and national HIV burden. Even following the collapse of many commodity markets, most economies in sub-Saharan Africa continue to expand. Decision-makers in Africa and other parts of the world need to leverage this economic growth to support HIV prevention, care and treatment programmes, recognizing that these investments generate 15:1 economic returns by increasing labour productivity, averting future medical expenses, and improving outcomes for children9.
Reducing donor funding now would further disincentivize countries from increasing their spending, and waste previous investments – leaving many countries unable to sustain or build on the gains made in recent years. It would also punish countries that have increased domestic resources but cannot yet afford the full burden of their epidemic.
Investing in the health workforce
In the AIDS response, people are our most important resource. Health systems do not treat people living with HIV or prevent new HIV infections. People do. The healthcare workers who labour every day – often against considerable challenges – are the front line of our response to HIV, and the response is serving them insufficiently.
In many countries, health workers are in extremely short supply. The workforce shortage, already estimated at 7.2 million, is projected to grow to 12.9 million by 203510. In more than 80 countries, the population-level density of health workers falls short of the minimum threshold recommended by WHO.
These shortages mean that we need to do everything possible to support and value the healthcare workers we have. Far too often, though, we fail the healthcare workers on whom we must rely if we hope to drive down new infections and AIDS-related deaths. Too many healthcare workers lack the tools they need, are underpaid, work in challenging environments, receive inadequate continuing education, and have few opportunities to advance in their field.