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#InDevelopment: The biggest question at AIDS 2016 - how do we find the money and momentum to sustain the HIV response?

In July our #InDevelopment blog series is marking the International AIDS Conference 2016 – this year’s theme is Access Equity Rights Now. Our experts will explore a number of pertinent themes. The conference, being held in Durban, South Africa, is the premier gathering for those working in the field of HIV, as well as policy makers, persons living with HIV and other individuals committed to ending the pandemic. In the second blog of our series, Health Financing experts Catherine Barker and Thomas Fagan discuss the financial challenges we face in eradicating HIV and the innovative approaches to financing that have the potential to revolutionise our response.

Health Financing experts Catherine Barker and Thomas Fagan are part of Palladium's delegation to this year's International AIDS Conference in Durban, South Africa.

A defining conference for young HIV economists
The 2000 International AIDS Conference in Durban generated political support and financial investment in HIV, and has been described as a turning point in the HIV response. We did not attend the 2000 conference – in fact, we were just children unaware of our future careers in the field of HIV economics – but we can feel the significance of being in Durban now for the 2016 conference. We are here at another critical juncture in the global HIV response. While some claim we have the right tools to end HIV and that the end is in sight, others fear the progress made over the last 16 years is in jeopardy and we have a long road still ahead. As part of the next generation leading the fight against HIV, we believe it is our responsibility to learn from the past and find innovative approaches to make the dream of an AIDS-free generation a reality in our lifetime.

In 2000, treatment for people living with HIV was just being introduced, anti-retroviral drugs (ARVs) cost about $10,000 per patient per year, and PEPFAR and The Global Fund did not exist. Today, the cost of ARVs is around $100 per patient per year. Over $19.2 billion was spent on HIV in 2014 in low- and middle-income countries, resulting in nearly 17 million people living with HIV on treatment, according to UNAIDS. There have also been advances in human rights in an effort to ensure no one is left behind. This past weekend, we had the privilege of attending pre-conference sessions focused on the unique needs of transgender people and adolescents living with HIV; this is the first time these groups have received such attention at an international AIDS conference.

The number of people on ART has increased globally, but more resources are needed to scale up treatment and meet 90-90-90 targets.

The financial and social challenge: how to sustain the HIV response?
Despite this progress, challenges remain. About half of people living with HIV are not on treatment, and many don’t even know their status. Stigma and discrimination is still pervasive, and adolescent girls, young women, and key populations are not receiving the support they need. Furthermore, HIV investments need to increase by one-third from 2014 to 2020 to meet Fast Track Strategy targets, yet external funding for HIV has plateaued in recent years and a new Kaiser report found that donor funding actually declined from 2014 to 2015. There is a great deal of emphasis on shared responsibility and domestic resource mobilization. However, many countries already contribute significantly to their HIV responses and face fiscal constraints – including slow economic growth and competing government priorities – that limit their ability to fill the funding gap for HIV. And even if the world mobilized enough resources to achieve the 90-90-90 targets, we still have the concern of how to reach the ’final 10%’ – who may well be some of the most vulnerable members of society.

One message we hear clearly is that there is no ’magic bullet’ solution to achieving sufficient and sustainable financing for the global HIV response. New domestic financing in high-HIV prevalence countries will be necessary. This can potentially be harnessed through innovative financing approaches; such as earmarking taxes or integrating HIV into universal healthcare coverage. External financing and support is also critical; The Global Fund replenishment meeting this September may be the forum for countries to reaffirm this commitment. At the same time, greater efficiency in HIV service delivery to reduce costs and maximise investment is a priority as the global community aims to achieve the Fast Track targets.

At this year's International AIDS Conference, Health Policy Plus is contributing evidence on how the field can improve access, equity and rights in the global HIV response.

Our approach to Health Financing – Health Policy Plus
At the International AIDS and Economics Network pre-conference event, we had the opportunity to present our own work on assessments of HIV sustainable financing in Zambia, Uganda, and Tanzania and projections of financing needs and availability for ART across 97 countries. We also learned first-hand from our colleagues who presented on research and the implementation of new approaches in other countries.

Our work under the USAID- and PEPFAR-funded Health Policy Project has found that countries face widespread health system constraints, ranging from shortages in health workers to insufficient financing, that hinder the scale-up of HIV services. For instance, the funding gap for universal adoption of test-and-start treatment in our 97-country analysis is estimated to be about US$21 billion from 2016 to 2020, with the country-specific financing gaps ranging from zero to 95 percent of the projected resource needs over the same period. Although a combination of resource mobilization and efficiency measures are needed to address this funding gap, solutions need to be evidence-based and tailored to the country. Middle income countries face different issues than low income countries, particularly regarding accessibility to affordable ARVs.

Hopes for #AIDS2016
Even though this is our first International AIDS Conference, it is clear to us how far the response has progressed over the past 16 years. Yet, much work remains. More than ever, the global community must re-commit itself to ending the epidemic, and even as we face new, emerging health issues, it will be our generation’s responsibility to ensure that we do not lose sight of our shared goal: an AIDS-free generation. We feel honoured to have the opportunity to share our work and contribute to the way forward for HIV sustainable financing. We hope issues around sustainable financing will be discussed in even greater detail throughout this week’s sessions, and that additional ideas can be generated through the power of convening experienced and young researchers, health workers, civil society members, donors, industry representatives, and people living with HIV in one place.

InDevelopment is Palladium’s blog series exploring emerging, cutting-edge and profound themes in global development. You’ll hear from our global experts and guests every two weeks. For more from Palladium’s International Development work follow us on Twitter, LinkedIn, Facebook and at #InDevelopment.


About the authors

InDevelopment July contributors: our health experts Catherine Barker and Thomas Fagan (middle).

Catherine Barker is a Senior Associate for Health and Thomas Fagan is an Associate for Health at Palladium. Both are members of the health financing team on the Health Policy Plus project.