Trends in HIV Financing: More, Better and (Eventually) Less

The "End of AIDS" is not yet here. But, for the first time, we can see it on the horizon.
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At the XIX International AIDS Conference (AIDS 2012) in Washington, DC this week, there will be -- justifiably -- much talk about the significant scientific advances in the fight against HIV/AIDS of the last two years, and how we cannot squander this unprecedented opportunity to break the back of the AIDS pandemic.

But there will also be those among the 20,000 scientists, researchers, clinicians, activists and journalists present who will say that we risk allowing the global economic crisis to distract us from our ultimate goal -- the end of AIDS.

To set the stage, the Kaiser Family Foundation and UNAIDS released a report last week on donor funding in 2011 showing that "donor nation support for HIV stands firm but investments remain at 2008 levels." The U.S. Government continues to account for more than half of all donor government investments.

Those who worry that Western donor countries are carrying too much of the load will be encouraged -- and surprised -- by the revelation in UNAIDS' new report "Together We Will End AIDS" that more than 80 countries have increased their domestic HIV/AIDS investments by over 50% in the last five years, and exceeded international investments for the first time.

But despite these increases in domestic funding, there is still a large shortfall in overall global funding for HIV -- some $7 billion, according to the UNAIDS report.

Furthermore, more and more of that funding is not being spent in a targeted way: The majority of HIV-positive people now live in middle income countries but funding for HIV is increasingly being directed to low income countries. "This means that interventions for most at-risk population are in danger of being seriously underfunded, which in turn will very likely lead to more new infections," according to the International HIV/AIDS Alliance, a global partnership of 39 organizations working to support community action on AIDS in developing countries.

I am hearing three distinct things on HIV financing at the AIDS conference in Washington:

•We need to spend more money now to capitalize on the recent scientific advances and findings in order to reach the tipping point that will lead to the defeat HIV/AIDS. UNADS Executive Director Michel Sidibé puts it in stark terms: "Pay now or pay forever."

•We need to spend the money that is allocated more wisely, to have more impact for the same or less money. This idea is variously described as "know your epidemic" and "smart investments."

•And, for the first time, a model has been developed that shows a decline in the need for HIV programs and services, as the effect of current and future targeted investments reach a tipping point, the so-called "investment framework for HIV/AIDS," first published in The Lancet in 2011.

Let's take those one by one:

Quantity of Funding: The KFF/UNAIDS report shows that investments to fight HIV/AIDS overall remain at 2008 levels, when recession hit world economies and created havoc with their budgets. This financial paralysis came at a time when more people than ever were getting access to prevention, care and treatment (in Africa alone, 22 countries experienced drops in new infections of 25% or more) and when new strategies promised to deepen that impact further.

Everyone is talking about innovative financing for health but the Alliance is concerned that the strategies being considered are far from innovative or new. Many in civil society are advocating for a Financial Transaction Tax (also called the "Robin Hood Tax") which could raise an additional $30-$50 billion that could help pay for the end of AIDS but there seems little appetite in some donor countries, such as the U.S., for such a tax.

Quality of Funding: An increasing number of NGOs are making the case for measuring and improving the "value for money." One example of this is the Alliance adapting a Social Return on Investment (SROI) methodology for use at the community level and applying it to the Khana Integrated Care and Prevention Program in Cambodia. This method allows program participants to quantify their own benefits in the form of social, health and economic-related values, thus generating a return on investment.

Investment Framework for HIV/AIDS: Last year, The Lancet published a new model that projects an increase in spending on HIV/AIDS leading up to 2015, followed by a decline in spending from 2015 to 2020. This was the first time a formal model had been developed foreseeing an end to the rising costs of the AIDS pandemic.

More precision in financing is key if we are to prevent the current financial crisis from having a heavy fallout on the communities who are on the frontline of the epidemic. With appropriate and properly targeted resources, we can halt and reverse the spread and impact of HIV.

The "End of AIDS" is not yet here. But, for the first time, we can see it on the horizon.

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