A new discussion paper released by ICASO and EANNASO suggests that the Global Fund might not be investing enough money in HIV prevention in Africa to meet its targets. In its new strategy, the Global Fund has set ambitious new targets for HIV prevention. The Fund aims to achieve a 38% reduction in new infections over the 2015-2022 period, including a 58% reduction in HIV incidence in adolescent girls and young women aged 15-24 (see GFO article). The discussion paper frames resource needs for HIV prevention in terms of global estimates. UNAIDS has modelled that ending AIDS by 2030 will cost about $25 billion a year, with a quarter (26%) of this amount required for HIV prevention. The paper confronts the reality that the benchmark of investing “a quarter for prevention” is not being met, and progress on HIV prevention has stalled as a result. Indeed, since 2010, the number of new adult HIV infections has remained unchanged, with an estimated 1.9 million occurring globally each year. The research is also contextualized as follow-up to the recent expert meeting to Fast-Track HIV prevention implementation in 15 eastern and southern African countries, held on 23-24 March 2017 in Victoria Falls, Zimbabwe. At this meeting, the Interim Executive Director of the Global Fund, Marijke Wijnroks, presented a call to action on HIV prevention. One of the key objectives of the meeting was to explore opportunities for increasing investments for HIV prevention in the Eastern and Southern African Region, including through the Global Fund applications for the 2017-2019 funding cycle. To support advocacy for increased investments in the 2017-2019 funding cycle, researchers from ICASO and EANNASO set out to determine current Global Fund investments in HIV prevention in a sample of 25 African countries over the 2014-2016 funding cycle. Funding requests (or “concept notes” as they were called at the time) were accessed for 23 countries, and signed grant agreements were accessed for 15 of them. Some documents were not publicly available. Of the 23 funding requests examined, an average of 16% of the total funding requested was dedicated to HIV prevention (see Figure 1). Mauritius’ request for HIV prevention was the largest (proportionally), at 67%. The smallest proportional requests for HIV prevention interventions came from Mozambique (3%) and Swaziland (3%). The authors note that PEPFAR is a large investor in HIV prevention in Mozambique and Swaziland. As a result, the gap for the Global Fund to fill in these countries may have been smaller.

Figure 1: Proportion of HIV and TB/HIV Global Fund funding requests dedicated to HIV prevention interventions (2014-2016 funding cycle)

Of the 15 signed grant agreements examined, an average of 15% of the total funding invested was dedicated to HIV prevention (see Figure 2). This is slightly less than the 16% requested. Just two countries – Botswana and Liberia – had at least 26% of their Global Fund grant budgets dedicated to HIV prevention interventions. Liberia’s grant had the largest proportion of HIV prevention funding, at 38%, while Mozambique’s had the smallest, at 4%.

Figure 2: Proportion of HIV and TB/HIV Global Fund signed grant agreements dedicated to HIV prevention interventions (2014-2016 funding cycle)

The paper states that both within-allocation and above-allocation amounts for HIV prevention were included in the analysis of funding requests. This may help to explain why so many more countries requested “a quarter for prevention” as compared to those that achieved this level of funding in their signed grant agreements. However, it should be noted that, on average, the proportion devoted to HIV prevention in the funding requests (16%) and the proportion devoted to HIV prevention in the actual grant agreements (15%) were largely similar. The authors call attention to the particularly low levels of investments in HIV prevention among key populations. “Underspending on prevention hurts communities that face disproportionate rates of new infections,” says Mary Ann Torres, Executive Director of ICASO. “This is especially true for adolescent girls and young women, men who have sex with men (MSM), transgender people, sex workers, people who use drugs, indigenous people, and people in detention.” The analysis shows that just 3% of HIV and TB/HIV programs in grants to 15 African countries are spent on HIV prevention among sex workers, MSM, transgender people and people who inject drugs. In the current funding cycle (2017-2019), the Global Fund aims to have 39% of investments in signed HIV and TB/HIV grants dedicated to programs targeting key populations (see GFO article). This is a key performance indicator (KPI) to measure the success of the Fund’s corporate strategy. Concerted advocacy will be required to increase spending on key populations in order for the Global Fund to achieve this KPI. The discussion paper illustrates some of these disparities. Adolescent girls in South Africa are eight times more likely to contract HIV than their male peers. Sex workers in Ethiopia have an HIV prevalence of 24.3 % – more than 16 times the national adult average of 1.5%. The paper also raises concern that the Global Fund’s HIV prevention investments appear to be decreasing over time. According to the Fund’s 2012 results report, cumulative Global Fund grant expenditure on HIV prevention from 2002-2011 was 30% of all HIV spending – twice the proportion found in this study. The authors emphasize that any comparison of current and historical HIV prevention spending must acknowledge that millions more people now require sustained antiretroviral therapy (ART), much of which is procured through Global Fund grants. One of the paper’s recommendations is to encourage countries to increasingly absorb critical aspects of their HIV response – especially ART – into domestically-funded programs. This would enable the Global Fund to invest more in HIV prevention interventions, towards achieving its HIV prevention KPIs. Another recommendation is to capitalize on opportunities with catalytic funding, especially the matching funds, as a new way to increase Global Fund investments in HIV prevention. Aidspan has previously reported on catalytic funding here, here and here. For matching funds, the $50 million set aside for HIV programs for key populations and the $55 million for HIV programs for adolescent girls and young women are critical opportunities to increase prevention spending among these groups. “Sustaining community advocacy on HIV prevention investments is absolutely critical,” says Olive Mumba, Executive Director of EANNASO. “Our results show that now, more than ever, we need to invest in communities to revitalize the prevention agenda.” This week, the UNAIDS Programme Coordinating Board (PCB) is meeting in Geneva. The third day of the meeting (29 June 2017) will be dedicated to the thematic segment “HIV Prevention 2020: a global partnership for delivery.” ICASO and EANNASO’s discussion paper forms part of the background note for the PCB, and will be shared during the thematic segment.
Dr. Gemma Oberth is the lead author of this discussion paper. It was produced in her capacity as a policy advisor for ICASO.