Financing of HIV/AIDS programme scale-up in low-income and middle-income countries,

Financing

Financing of HIV/AIDS programme scale-up in low-income and middle-income countries, 2009-31

Hecht R, Stover J, Bollinger L, Muhib F, Case K, de Ferranti D., Lancet. 2010 Oct 9;376(9748):1254-60.

As the global HIV pandemic nears the end of its third decade, the challenges of efficient mobilisation of funds and management of resources are increasingly prominent. The aids2031 project modelled long-term funding needs for HIV in developing countries with a range of scenarios and substantial variation in costs: ranging from US$397 to $722 billion globally between 2009 and 2031, depending on policy choices adopted by governments and donors. Hecht and colleagues examine what these figures mean for individual developing countries, and estimate the proportion of HIV funding that they and donors will provide. Scenarios for expanded HIV prevention, treatment, and mitigation were analysed for 15 representative countries. The authors suggest that countries will move in increasingly divergent directions over the next 20 years; middle-income countries with a low burden of HIV will gradually be able to take on the modest costs of their AIDS response, whereas low-income countries with a high burden of disease will remain reliant upon external support for their rapidly expanding costs. A small but important group of middle-income countries with a high prevalence of HIV (eg, South Africa) form a third category, in which rapid scale-up in the short term, matched by outside funds, could be phased down within 10 years assuming strategic investments are made for prevention and efficiency gains are made in treatment.

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Editors’ note: This article about key long-term financing issues for low- and middle-income countries and their external funder partners makes for sobering reading. It challenges us to consider four scenarios from now to 2031 based on assumptions about political will, available resources, and strategic approaches. They are ‘current trends’, ‘rapid scale-up’, ‘hard choices’, and ‘structural change’. ‘Rapid scale-up’ would prevent 7 million more deaths and 14 million more infections than ‘current trends’ but would require a ratcheting up of resources to $35 billion per year in 2031 (compared with $24 billion that year for ‘current trends’). For comparison, in 2009 $15.9 billion was spent on HIV in low- and middle-income countries. ‘Hard choices’ concentrates on proven cost-effective interventions and prioritises populations at higher risk of HIV exposure, with the result that resource needs are the lowest ($18.5 billion in 2031) and 6 million deaths are prevented compared with ‘current trends’. Although ‘hard choices’ achieves the most cost-effective results for prevention, ‘structural change’ would have the greatest effect for reduction of future spread of HIV and would cost $3 billion less per year by 2031 than ‘rapid scale-up’. Structural change would invest in strategies to reduce gender-based violence and stigma and discrimination, modify employment practices to support family integrity, and address other underlying social determinants of HIV. This article explores policy options for countries and external development partners, while underscoring that this is no time to neglect investment in research and development to generate game-changing prevention technologies and a cure.