What can developing countries do now to change the trajectory of the AIDS epidemic for decades to come? How much will it cost to avert new infections and expand access to treatment? Which countries will be able to take full ownership of their HIV/AIDS responses, and which will continue to rely on international support?
In a Review in this week's Lancet, authors from the financing group of the aids2031 project address these critical questions, taking a long-term view of the financial requirements under possible scenarios as the HIV/AIDS pandemic unfolds over the next two decades up to 2031, the year that will mark the 50th anniversary of the discovery of HIV/AIDS.
The aids2031 financing group, a high level panel composed of global experts, is headed by the Results for Development Institute (R4D), based in Washington DC, USA.
Dr. Robert Hecht, a managing director at R4D and lead author of the Review, reports that, "Over the next two decades to 2031, total spending on HIV/AIDS in low and middle income countries will range from a low of US$397 billion to as much as $722 billion. These are huge numbers, especially in the current economic environment. But countries do have distinct options for spending smarter and better."
The lower estimate is based on countries adopting what the group calls a "hard choices" approach, in which they target efforts to proven, highly effective prevention activities, while the higher estimate is based on rapid-scale up of current technologies and treatments to all those in need.
Their modelling estimates include potential new technologies such as microbicide gels and account for the preventive effects of antiretroviral drugs as currently prescribed.
The authors note with concern the effects the global economic crisis and the recent leveling off of development assistance for the HIV/AIDS response. They warn that a stagnation of funding at 2009 levels could see a rise in new infections to 3.2 million in 2015, compared to 2.3 million in 2009.
The authors highlight three groups of countries moving in different directions and facing diverging future HIV/AIDS costs and financing challenges: high disease burden low-income (HBLI); low disease burden middle-income (LBMI), and high disease burden middle-income (HBMI).
The situation is especially worrying for the first set of countries, according to Hecht. "The unprecedented situation in HBLI countries such as Zambia, Mozambique, and Malawi is unlikely to improve in the next few years. Continued high HIV incidence means spending needs will escalate, especially as antiretroviral (ART) programmes expand according to the new WHO-recommended treatment guidelines."
"Even middle income countries with severe epidemics such as Botswana, Namibia, and South Africa are likely to require significant external support in the short to medium term, as they deal with the twin challenges of lowering new infections through intensified prevention and catching up with the huge backlog of unmet need for treatment."
Financial prospects for the low-burden, middle-income (LBMI) countries are very different from those for HBLIs. Many of these countries, including Brazil, Mexico,
Thailand, and Ukraine, have the domestic capacity to cover most, if not all, future HIV/AIDS costs. In 2008, HIV/AIDS spending requirements in these countries were well below 1% of GDPs and generally less than 4% of total health expenditures.
The authors estimate that over the next two decades, HIV/AIDS funding requirements in these countries will remain modest. Governments can sustain HIV spending using domestic resources, provided that there is political will to assist marginalized sub-populations such as injecting drug users and men having sex with men, where the epidemic is concentrated.
The authors of the Review argue that these diverging long-run prospects point to different strategies for donor agencies such as the Global Fund and the U.S. PEPFAR. HBLI countries will likely need external donor support for decades to come, while in LBMI countries donors can act as catalysts for a few years while gradually transitioning away, as national governments assume responsibility for financing their own HIV/AIDS programs.
To date, about 38% of PEPFAR funds and 27% of Global Fund grant disbursements have gone to middle-income countries. Even if high burden South Africa, Botswana, Namibia, and Swaziland are excluded, 18% of PEPFAR and 21% of Global Fund resources are still allocated to middle-income nations.
The authors conclude: "In the next few years, sustaining momentum will be difficult in the face of global economic slowdown, competing issues such as global climate change, and the increasingly divergent situations of countries with different epidemic burdens and economic capacities. Rather than deny these differences, we need to accept and embrace them to design customised responses and maintain solidarity and aims in our global efforts to end HIV/AIDS."
For interviews with Dr. Robert Hecht contact: Mame Annan-Brown, Results for Development Institute, Washington, DC, USA. T) +1 347 564 2936 mannan-brown@resultsfordevelopment.org Skype: mameannanb
For full Review see: http://press.thelancet.com/aids2031.pdf
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The Lancet