During the last decade, the world recorded substantial progress in the fight against the global HIV epidemic: AIDS-related deaths reduced by one third, and new HIV infections reduced by a 16%, between 2010 and 2018. However, dwindling financial resources available for HIV and a growing epidemic in some regions, such as Eastern Europe and Central Asia, threaten these gains, which are already diminishing year-on-year. In fact, the world is unlikely to meet the global HIV targets laid out in UNAIDS’ 'Fast-Track: Ending the AIDS epidemic by 2030', which includes a reduction in new annual infections to fewer than 200,000 by 2030 (or in the more immediate term, fewer than 500,000 by 2020). Renewed efforts are needed to sustain the gains already achieved while also accelerating progress towards ending the epidemic.
This article focuses on three main factors that are key to building on past achievements: domestic investments in the HIV response, HIV prevention, and the role of communities.
The information in this article comes from discussions held in a panel session called ‘Sustaining the AIDS response,’ convened by the Joint United Nations Programme on HIV/AIDS (UNAIDS) at the 20th International Conference on AIDS and Sexually Transmitted Infections in Africa (ICASA) held in Kigali, Rwanda from 2 to 7 December 2019. Panelists included Peter Sands and Winnie Byanyima, Executive Directors of the Global Fund and UNAIDS, respectively, and Maureen Murenga, who is the Executive Director of Lean on Me Kenya. We also obtained information from the UNAIDS Data 2019 report, the Global AIDS Update 2019, and other available literature and analysis.
Key considerations in sustaining the HIV response
HIV response needs more domestic resources and increased accountability
Panelists in the UNAIDS session expressed their concern for the low level of domestic investments in the HIV response across sub-Saharan African countries. Indeed, recent statistics by UNAIDS showed that sub-Saharan Africa countries rely mostly on external resources to fund their HIV responses. Two regions make up sub-Saharan Africa: Eastern and Southern Africa, and West and Central Africa. In both regions, external sources fund more than half of the HIV responses. In Eastern and Southern Africa, donors fund 59% while in West and Central Africa they fund 62%. In Eastern and Southern Africa, when South Africa is excluded from the analysis, donor funds account for 80% of the HIV response. (South Africa is one of the few African countries that funds its HIV response using mostly domestic resources [78%].)
The situation is not all doom and gloom - over the years, countries have been taking more responsibility for their responses. The two regions in sub-Saharan Africa have raised their investments since 2010. Countries in Eastern and Southern Africa, which is home to 54% of the world’s people living with HIV, increased their domestic contributions by 34% between 2010 and 2018 while West and Central African countries increased theirs by 30%, according to UNAIDS. However, the level of domestic investments fell in 2018, particularly for Eastern and Southern Africa, by 9% (or by 27% if South Africa is excluded from the analysis).
Peter Sands, Executive Director of the Global Fund, which remains a major global financer of HIV responses contributing about 20% of all international financing globally for the three diseases, particularly in sub-Saharan Africa, urged countries to raise additional domestic resources and to spend enough of these resources on health, particularly on the right programs and for populations that are most in need. (The GFO reported on this in more detail in December 2019). The Global Fund projects that implementing countries will raise $46 billion in domestic resources for the three diseases over the 2021-2023 grant implementation period through their co-financing commitments. Panelists recommended that countries should strengthen revenue collection systems and increase efficiency in the use of resources.
The session also underscored the critical role of countries’ Parliaments in promoting increased countries’ financial allocations to the health sector, particularly to the HIV response, through their budgetary processes. Parliament can also ensure increased accountability of both domestic and external financing for HIV in collaboration with the Offices of the Auditors-General, or their equivalent.
[Editor’s note: Aidspan, cognizant of the need for countries to increase accountability, is currently working with Supreme Audit Institutions in eight Anglophone and Francophone countries to improve their readiness to audit Global Fund grants in their countries. Read more on the strengths of the Audit office of Kenya, Ghana and Rwanda in auditing their grants.]
“We are mopping the floor with the tap open” – building the case for HIV prevention
Countries have failed to collectively meet the global target of fewer than 500,000 new annual HIV infections by 2020. Approximately 1.7 million people became newly infected with HIV in 2018, according to recent statistics by UNAIDS. These new infections continue to add to the pool of people living with HIV, which further increases the total HIV resource needs, a situation that one of the panelists, Maureen Murenga, equated to “mopping the floor with the tap open.” Currently, more than 37.9 million people globally are living with HIV.
While sharing her perspective on sustaining the AIDS response, Murenga noted three ‘mistakes’ that are working against the HIV response. The first mistake is the medicalization of the HIV response. “We think it’s as easy as buying drugs and putting them in the health facility, yet we know that there are a lot of barriers between the house and the health facility related to gender, human rights, and stigma,” she explained. The UNAIDS HIV Prevention Roadmap 2020 recommends a combined approach to HIV prevention that includes a range of biomedical, behavioural and structural (relating to policy and human-rights barriers) interventions.
Murenga cited the second mistake as the failure to use data to inform decision making and strategic investments. Likewise, UNAIDS had noted, in 2015, that HIV prevention investments did not always target the people most in need of the services, which alludes to gaps in the use of evidence to inform programming, Lastly, she noted that prevention programs sideline people already living with HIV despite the potential for them to help design effective prevention programs.
On the one hand, investing in HIV prevention will reduce the resources needed to care for those who become infected with HIV, as demonstrated in the UNAIDS Fast-Track targets. The Fast-Track strategy estimates that investing to avert 28 million new HIV infections between 2015 and 2018 would deliver a 15-fold return on those investments, including saving $24 billion in additional HIV treatment costs based on infections averted. But on the other hand, countries’ investments in HIV prevention are not often commensurate with the rate of new HIV infections.
Countries apportioned an average of 16% of their HIV allocation to HIV prevention, according to an analysis of funding requests submitted to the Global Fund by a sample of African countries in the 2014-2016 funding cycle. This proportion falls short of the UNAIDS benchmark of 26%. In the 2017-2019 cycle, Eastern and Southern African countries dedicated only 4.6% of total HIV funding for prevention programs among adolescents and youth, despite the region having the worst burden of HIV infection across this age group, according to an Aidspan analysis in October 2018. Adolescent girls and young women aged 15 to 24 years accounted for 26% of new infections in the region in 2018, according to recent UNAIDS statistics.
Panelists urged the countries to increase their investments in HIV prevention. Winnie Byanyima, UNAIDS Executive Director, urged African countries to take up more responsibility and ownership of HIV prevention efforts instead of transferring that responsibility to donors to ensure sustainability. “We [African countries] should be putting more of our resources on prevention,” she said. This call echoes the 2016 United Nations General Assembly Political Declaration on ending the AIDS epidemic by 2030, where countries committed to invest at least a quarter of total HIV resources in HIV prevention in line with the UNAIDS ‘Quarter for Prevention’ benchmark created in 2015.
The panelists further noted that prevention efforts should target key and vulnerable populations, depending on the country context. This call is timely as recent statistics by UNAIDS now show that key populations and their sexual partners account for more than half of new infections. It is therefore vital that countries use existing data to inform investments in HIV prevention efforts.
Winnie Byanyima described prevention efforts targeted to adolescent girls and young women as a ‘game-changer’ within the African context where HIV infection is 60% more likely for young women (15-24 years) than for young men of the same age. She called for increased investments in sensitization about young women’s sexual and reproductive health rights, and for stricter implementation of laws on violence against women, which exacerbates the risk of HIV infection for women.
Putting communities at the center of the response
Lack of information or ignorance, stigma and discrimination, and other human rights-related barriers often hinder access to HIV prevention, testing, and treatment services, particularly for marginalized populations. However, communities have stepped in either as service providers, advocates, and human-rights defenders to bridge this gap and ensure that the services are relevant to, and reach, the people who need them most There is no standard definition of ‘communities’, but the term usually refers to people living with or affected by the three diseases, and to key and vulnerable populations. For instance, efforts by community health workers, who provide services at the community level, have helped South Africa and Zambia achieve the 90-90-90 targets, and have improved circumcision rates in Kenya, according to UNAIDS.
As advocates, community members have helped reduce legal barriers to accessing HIV services. According to UNAIDS, in Colombia and parts of Mexico, communities have helped overturn laws that criminalized HIV transmission. In at least nine countries in sub-Saharan Africa, they have helped decriminalize same-sex sexual relationships.
Despite clear evidence in favor of community-led interventions, communities still face numerous challenges contributing to the HIV response. Community responses in most countries are grossly underfunded and rely mainly on foreign resources. It is not clear what proportion of Global Fund investments support community responses, but the Global Fund notes on its website that it encourages countries to allocate funding to initiatives such as community-based monitoring, community-led advocacy, social mobilization and institutional capacity building. However, Maureen Murenga noted that community interventions or responses are usually the biggest (and first) losers in the event of reduced donor funding.
Panelists called for increased funding for community responses, including advocacy work, which enables the communities to lobby consistently for increased funding and for better HIV services. One way African governments might do this would be to honor their collective commitment, made in the 2016 HIV Political Declaration, to invest at least 6% of total HIV resources on ‘social enablers’, including advocacy, community and political mobilization, community monitoring, outreach programmes and public communication by 2020, and ensure that at least 30% of all service delivery by 2030 is community-led.
- ‘Fast-Track – Ending the AIDS epidemic by 2030’
- UNAIDS Data 2019 report
- Global AIDS Update 2019 – Communities at the centre
- From GFO Issue 370, 19 December 2019, “Global Fund Executive Director calls for increased domestic investment in health at ICASA meeting in Rwanda”
- UNAIDS HIV Prevention 2020 Road Map
- Gemma Oberth, Mary Ann Torres, Olive Mumba & Michel O’Connor. A Quarter for Prevention? Global Fund Investments in HIV Prevention Interventions in Generalized African Epidemics, 2017
- From GFO Issue 344, 17 October 2018, Global Fund grants underfund HIV prevention among adolescents, the key driver of the epidemic in Eastern and Southern Africa
- 2016 United Nations Political Declaration on Ending AIDS sets world on the Fast-Track to end the epidemic by 2030