In the past 15 years, the global community has provided US$109.8 billion in development assistance to curb HIV/AIDS. Several international aid organisations created in this period have been instrumental in galvanising the resources needed to combat the epidemic.
But meeting the UNAIDS 90-90-90 targets – that 90% of HIV positive people will know their status, 90% of those people will be on antiretrovirals and 90% will be virally suppressed by 2020 – will require major changes in how programmes are delivered and financed.
Maintaining and scaling up the funding of AIDS efforts in the next 20 years to end the epidemic is crucial.
Current epidemiological and financial trends suggest there’s a major risk of a substantial shortfall in the funds required to sustain life-saving antiretroviral programmes.
The three phases of the epidemic
The number of people living with HIV/AIDS steadily increased to 38.8 million in 2015, according to the 2015 Global Burden of Disease study.
The unfolding global HIV pandemic has advanced through three phases. In the first phase, 1981 to 1997, HIV moved from being ranked as the 39th leading cause of death worldwide to the 11th.
In the second phase, from 1998 to 2005, incidence declined by 25.4%. But because of the lag between infection and mortality, the number of deaths caused by HIV increased.
In the third phase, from 2005 to 2015, the mass scaling of prevention of mother-to-child transmission and antiretrovirals – particularly in low-income sub-Saharan Africa – led to several developments. These included declining HIV mortality, a stagnation in the decline of global incidence rates and steadily rising prevalence. These global patterns mask well documented but extraordinary heterogeneity across countries.
The need for HIV programmes, particularly antiretroviral ones, keeps growing. This is due to both the sustained high number of infections and the success of antiretrovirals in extending the lifespan of people living with HIV.
Dealing with the financing gap
Enormous progress has been made in reducing HIV deaths. This is particularly true in low-income countries. But this is mainly because programmes that prevent mother-to-child transmission and antiretroviral interventions, largely funded through development assistance for HIV, have been expanded.
But the scarcity of adequate funds to provide antiretrovirals to people living with HIV – together with the possibility of rising drug resistance to existing antiretroviral treatments – will make achieving the goal to end AIDS by 2030 extremely difficult.
In middle-income countries, increased commitments to funding health programmes from national budgets could fill the gap.
But domestic resources won’t be sufficient in low-income countries where, as in eastern and some southern sub-Saharan African countries, HIV rates are the highest.
Researchers have projected that government health expenditure in southern sub-Saharan Africa is going to increase from $30.8 billion in 2015 to $53.1 billion in 2030.
Meeting the needs of people living with HIV will require a combination of the following evidence-informed strategies:
concentrating development assistance for HIV in these low-income countries;
improving the efficiency of HIV programmes;
increasing domestic financing;
lowering the cost of treatment (including the prices of antiretrovirals); and
reducing future incidence through more concerted efforts.
Development assistance efforts will also need to be scaled up if the free flow of low-cost generic drugs is hampered.
In 2015, only 41% of people living with HIV were receiving antiretroviral therapy. But the 90-90-90 goals imply that 81% should be receiving antiretrovirals and 73% will have viral suppression. No country has achieved this yet. To do so, antiretroviral coverage will need to be extended to at least 15.5 million additional people by 2020. This implies an addition of 3.1 million per year between 2015 and 2020, while ensuring complete treatment adherence.
It will require concerted efforts to scale up detection of new infections to meet the target of 90% of people knowing their status. The targeted expansion in antiretroviral therapy coverage would play an important part in reducing the still high number of people dying from HIV.
But such expansion has enormous cost implications in an era when even maintenance of coverage in some low-income settings could be at risk in the presence of declining development assistance for health.
Increased antiretroviral coverage might also play a part in reducing population transmission of HIV and therefore incidence. The quality of antiretroviral therapy embodied in the third 90 target of the UNAIDS strategy remains a major issue, as does the potential role of other care in extending survival.