Global Fund grants underfund HIV prevention among adolescents, the key driver of the epidemic in Eastern and Southern Africa
Africa’s Eastern and Southern regions have the highest prevalence of HIV globally, at 6.8%. Countries in these regions dedicated on average only 4.6% of their total Global Fund HIV/AIDS grant for HIV prevention among adolescents and youth for the 2018–2021 implementation period, according to Aidspan analysis.
This proportion is small considering the disproportionate toll HIV takes among adolescents and youth; while they represent 20.2% of the total population in the two regions, they contributed 36.3% to new HIV infections in 2017 (UNAIDS, 2018a). More worrisome, adolescent girls and young women (AGYW), who account for 10.1% of the Eastern and Southern African population, contributed to a quarter of the new HIV infections in these regions in 2017.
This article is based on a new Aidspan report that aimed to assess Global Fund investments for HIV prevention among adolescents and youth, and whether they differed by region, country income and HIV epidemiology. We focused on Eastern and Southern African countries for the 2018– 2021 implementation period.
Data for this analysis comes from several sources. We obtained data on Global Fund investment in HIV prevention from funding requests submitted by countries. A funding request is formatted into sections referred to as ‘modules’, such as prevention of mother-to-child transmission, HIV testing services, prevention programs for adolescents and youth (in and out of school), among others. We included only countries that had adolescents and youth, in and out of a school module, in their funding request. We obtained data on matching funds from the Global Fund website. Matching funds are meant to catalyze investments in Global Fund priority areas. The 2017 Gross National Income (GNI) per capita data came from the World Bank website. HIV epidemiology data came from UNAIDS. (For specific references, please see source list at the end of this article.)
The selected countries from the two regions of focus are:
- Eastern Africa: Kenya, Rwanda, Tanzania and Uganda
- Southern Africa: eSwatini (formerly known as Swaziland), Malawi, Mozambique, Namibia, South Africa, Zambia and Zimbabwe
For Kenya, Malawi, Mozambique, Namibia, Rwanda, Tanzania, Uganda, Zambia, and Zimbabwe the implementation period was January 2018 to December 2020, from the 2017-2020 allocation period. For eSwatini, the implementation period was October 2018 to September 2021 (Table 1).
South Africa is still implementing the grant from the previous allocation (2014-2017); its grant implementation period runs from April 2016 to March 2019, as it started late. The country is included in the analysis not only because it is the biggest economy in the region and home to the highest number of people living with HIV/AIDS (PLHIV) but also because its current grant implementation period overlaps with that of the other ten countries included in the analysis.
Table 1: Participating countries and their Global Fund implementation period
|Kenya, Malawi, Mozambique,
Namibia, Rwanda, Tanzania,
Uganda, Zambia, Zimbabwe
|eSwatini (formerly Swaziland)|
Eastern and Southern African regions varied both in economic status and HIV epidemiology. The Eastern Africa countries were mostly low income while the majority of Southern African countries are either lower-middle- or upper middle-income countries, as classified by World Bank (World Bank, 2018; see ‘Sources’ below).
In both regions, the HIV epidemic is generalized. However, East African countries had a lower prevalence of HIV among the general population and among AGYW than Southern African countries. For instance, Uganda had the highest HIV prevalence among adults (5.9%) and AGYW (2.9%) in the East Africa region in 2017. However, Uganda’s prevalence rates are lower than those in Malawi which had the lowest HIV prevalence among adults (9.5%) and AGYW (4.4%) in Southern Africa (UNAIDS, 2018b).
Owing to Global Fund matching funds, prevention programs for adolescents and youth receive 4.6% of the HIV grants' total funding
The ten countries (excluding South Africa) in this analysis requested a total of $2,127,478,146 from the Global Fund for the HIV component. Of this amount, prevention programs adolescents and youth receive $55,561,221, or about 2.6%.
On top of their allocation, countries could also receive additional “catalytic funds” from the Global Fund, though their use is carefully prescribed. Those catalytic funds from the Global Fund come in the form of matching grants, multi-country approaches and strategic initiatives. The matching grants could be used to reduce HIV incidence among AGYW, scale up HIV interventions for key populations and remove human-rights barriers to promote access to HIV services, according to the Global Fund.
These ten countries, except Rwanda, were eligible for additional Global Fund matching funds for HIV totaling $78,282,445. HIV prevention among AGYW received matching funds of $45,472,488. Adding the country allocation and the matching funds, the total Global Fund investment for the HIV component was $2,205,760,591, of which HIV prevention among adolescents and youth would receive $101,033,709 (4.6%) (Figure 1).
UNAIDS recommends that 26% of HIV funding should go to prevention (UNAIDS, 2015). Considering adolescents and youth’s share of new infections was 36.3% in 2017, prevention programs among them should receive about 9.36% (calculated as 36.3%, their share in new infections, of the 26% UNAIDS recommended share for prevention) of the total HIV funds from Global Fund.
In this current grant allocation period, only Namibia (18.7%) and eSwatini have followed or even surpassed this recommendation. Zambia is close with 8% but Rwanda is the farthest away with 0.1%.
Figure 1: Proportion of HIV/AIDS funding by the Global Fund for prevention programs for adolescents and youth (2018 – 2021 implementation period).
The higher the general HIV prevalence, the higher the proportion of funding for HIV prevention among adolescents and youth
Predictably, countries with higher HIV prevalence among AGYW allocate more resources to HIV prevention programs targeting this vulnerable group. Indeed, the analysis showed that the proportion allocated for HIV prevention among adolescents and youth is correlated with disease incidence and prevalence (Figure 2). For instance, Rwanda has a prevalence of 1.1% among AGYW and allocates 0.1% of its funding to HIV prevention among adolescents and youth. In contrast, eSwatini, with a prevalence of 16.7%, allocates 16.4% to prevention among this group.
Note that all of these countries receive PEPFAR funding for HIV prevention among AGYW. This type of other, external funding can affect the in-country allocation of Global Fund financing to adolescents and youth interventions.
Figure 2: Correlation between HIV incidence per 1000 and the proportion of HIV/AIDS funding for adolescents and youth prevention programs (2018 – 2021 implementation period).
The higher country income, the higher the proportion of funds allocated to HIV prevention among adolescents and youth
The analysis also showed that the proportion allocated to HIV prevention among adolescents and youth is positively correlated with a country’s income status (Figure 3). For instance, Mozambique has a GNI per capita of $420 and allocates 4.4% of its funding to HIV prevention among adolescents and youth. In contrast, Namibia with a GNI per capita of $4600 allocates 18.7% to prevention among this group.
Figure 3: Correlation between the GNI of a country and the proportion of HIV/AIDS funding by the Global Fund for adolescents and youth prevention programs (2018 – 2021 implementation period).
To end HIV/AIDS as an epidemic, there is a need to first control the epidemic by reducing the number of new HIV infections among AGYW in the Eastern and Southern African regions, where HIV prevalence is the highest. Matching funds provide incentives to those countries to prioritize HIV prevention among populations at high risk of new infections. Nevertheless, the proportion of spending on prevention for adolescents and youth is still too low in most countries in the regions, making a clear case to increase the average spending on AGYW in Eastern and Southern Africa.
- Aidspan. (2018). Global Fund Investments in Adolescents and Youth in Eastern and Southern Africa for the years 2018-2021.
- UNAIDS. (2015). Invest in HIV Prevention. In (pp. 16). Retrieved from http://www.unaids.org/sites/default/files/media_asset/JC2791_invest-in-HIV-prevention_en.pdf
- UNAIDS. (2018a). Number of New HIV Infections. http://aidsinfo.unaids.org/#menu3
- UNAIDS. (2018b). UNAIDS data 2018. In (pp. 376). Retrieved from http://www.unaids.org/sites/default/files/media_asset/unaids-data-2018_en.pdf
- World Bank. (2018). GNI per capita, Atlas method (current US$).