Human immunodeficiency virus funding and access to treatment in sub-Saharan Africa

Human immunodeficiency virus (HIV) treatment prevents illness, death, and transmission. The 90-90-90 disease control target is only 73% of people living with HIV virally suppressed. For 2010 to 2019, we abstracted HIV funding data for 40 countries in sub-Saharan Africa (70% of global HIV burden and >99% of HIV burden in the region in 2018). During 2010–2019, there was ∼$52 billion funding for 40 countries (99% Africa HIV burden). Domestic funding ranged from $0 to $3.2 billion. PEPFAR funding was $32 billion (average $1.4 billion; range $0.089–4.3 billion) among 22 countries. Global Fund averaged $306 million ($1.9 million to $1.1 billion) for 40 countries. Among PLHIV, known HIV status averaged 80% (11% to 94%). ART coverage averaged 64% (9% to 90%). Viral suppression among PLHIV ranged from 8% to 87%. Of the 40 countries, 21 reported under 60% of PLHIV to be on treatment and 13 did not report viral suppression for 2018. Achieving 90-90-90 is feasible in challenging settings if resources are used efficiently. Despite the significant investment in the HIV response, many countries have not reached the 90-90-90 target. Greater attention to efficiency and prioritizing important targets will be required to end AIDS in Africa.

Factors Related to HIV AIDS Fund Expenditure 2010-2018 (NASA 2019 Data Analysis)

The prevalence rate of HIV/AIDS and various achievement targets are still challenges in HIV/AIDS intervention in Indonesia. Indonesia is required to map out the current resources and their allocation in dealing with HIV AIDS. The objective of this study is to know the distribution and the factors that related with the HIV/AIDS expenditure in the year 2010-2018. This study uses a correlation study design derived from the 2019 National AIDS Spending Assesment (NASA) report and other data sources. The results of the study show that the total expenditure on HIV/AIDS programs in 2017 was 143,053,754 USD and decreased to 107,680,959 USD in 2018. Of the total expenditure, about 60% each came from public funding, an increase of 30% over 10 years. There is a strong relationship between HIV expenditure and the variables of reported HIV cases, ARV coverage, GDP growth and health budget. Total domestic expenditure on HIV and the total health budget had the strongest relationship (R=0.885) with a contribution of 78.3% effect on the health budget (p=0.001). The availability of domestic funds is still limited and is dominated by the allocation of treatment. The high level of dependence on international funding especially on prevention means that the architecture of HIV/AIDS funding needs to be reorganized to protect the sustainability of HIV funding.

Differential Association of HIV Funding With HIV Mortality by Race/Ethnicity, United States, 1999-2017

Objective Federal funds have been spent to reduce the disproportionate effects of HIV/AIDS on racial/ethnic minority groups in the United States. We investigated the association between federal domestic HIV funding and age-adjusted HIV death rates by race/ethnicity in the United States during 1999-2017. Methods We analyzed HIV funding data from the Kaiser Family Foundation by federal fiscal year (FFY) and US age-adjusted death rates (AADRs) by race/ethnicity (Hispanic, non-Hispanic white, non-Hispanic black, and Asian/Pacific Islander and American Indian/Alaska Native [API+AI/AN]) from Centers for Disease Control and Prevention WONDER detailed mortality files. We fit joinpoint regression models to estimate the annual percentage change (APC), average APC, and changes in AADRs per billion US dollars in HIV funding, with 95% confidence intervals (CIs). For 19 data points, the number of joinpoints ranged from 0 to 4 on the basis of rules set by the program or by the user. A Monte Carlo permutation test indicated significant ( P < .05) changes at joinpoints, and 2-sided t tests indicated significant APCs in AADRs. Results Domestic HIV funding increased from $10.7 billion in FFY 1999 to $26.3 billion in FFY 2017, but AADRs decreased at different rates for each racial/ethnic group. The average rate of change in AADR per US billion dollars was −9.4% (95% CI, −10.9% to −7.8%) for Hispanic residents, −7.8% (95% CI, −9.0% to −6.6%) for non-Hispanic black residents, −6.7% (95% CI, −9.3% to −4.0%) for non-Hispanic white residents, and −5.2% (95% CI, −7.8% to −2.5%) for non-Hispanic API+AI/AN residents. Conclusions Increased domestic HIV funding was associated with faster decreases in age-adjusted HIV death rates for Hispanic and non-Hispanic black residents than for residents in other racial/ethnic groups. Increasing US HIV funding could be associated with decreasing future racial/ethnic disparities in the rate of HIV-related deaths.

Leveraging the lessons learned from financing HIV programs to advance the universal health coverage (UHC) agenda in the East African Community

Background Although there is broad consensus around the need to accelerate progress towards universal health coverage (UHC) in Sub-Saharan Africa, the financing strategies for achieving it are still unclear. We sought to leverage the lessons learned in financing HIV programs over the past two decades to inform efforts to advance the universal health coverage agenda in the East African Community. Methods We conducted a literature review of studies reporting financing mechanisms for HIV programs between 2004 and 2014. This review is further underpinned by evidence from a mixed-methods study entailing a survey of 195 health facilities across Uganda supplemented with 18 semi-structured interviews with HIV service managers. Results Our data shows that there are six broad HIV financing strategies with potential for application to the universal health coverage agenda in the East African Community (EAC); i) Bi-lateral and multi-lateral funding vehicles: The establishment of HIV-specific global financing vehicles such as PEPFAR and The Global Fund heralded an era of unprecedented levels of international funding of up to $ 500 billion over the past two decades ii) Eliciting private sector contribution to HIV funding: The private sector’s financial contribution to HIV services was leveraged through innovative engagement and collaborative interventions iii) Private sector-led alternative HIV financing mechanisms: The introduction of ‘VIP’ HIV clinics, special ‘HIV insurance’ schemes and the rise of private philanthropic aid were important alternatives to the traditional sources of funding iv) Commodity social marketing: Commodity social marketing campaigns led to an increase in condom use among low-income earners v) The use of vouchers: Issuing of HIV-test vouchers to the poor was an important demand-side financing approach vi) Earmark HIV taxes: Several countries in Africa have introduced ‘special HIV’ taxes to boost domestic HIV funding. Conclusions The lessons learned from financing HIV programs suggest that a hybrid of funding strategies are advisable in the quest to achieve UHC in EAC partner states. The contribution of the private sector is indispensable and can be enhanced through targeted interventions towards UHC goals.

She's Married, She's Faithful, She's Dying: Politicizing the President's Emergency Plan for AIDS Relief

Conservative Christians played a significant role in pioneering the United States’ groundbreaking anti-HIV funding initiative, the President's Emergency Plan for AIDS Relief (PEPFAR). Consequently, PEPFAR is widely regarded as George W. Bush's crowning achievement. The same political forces that ushered in PEPFAR under President Bush were also the architects of strict ideological restraints around the otherwise straightforward public health goal of curbing the spread of HIV/AIDS. In recent years, some of these restrictions have been rolled back or struck down by the U.S. Supreme Court, and PEPFAR has continued to serve a crucial role in global health and security. PEPFAR's future success in achieving its health mandate (to create an AIDS-free generation) will be influenced by lessons from its past. This article illuminates how, in its first decade, PEPFAR was directed toward the fulfillment of socially conservative goals that ran counter to its official agenda. This was accomplished in large part through two controversial provisions: the “anti-prostitution pledge” (2003–2013) and the “conscience clause” (2003–present). Working in tandem, these policies sought to secure funding for organizations that favored abstinence and fidelity rather than a multisectoral approach to AIDS prevention.