The future of HIV epidemics and funding

New modelling has offered governments and donors a glimpse into the future of HIV epidemics - and what it will cost to prevent and treat them. Researchers warn of hard choices ahead and a need for some countries to take more responsibility for their national programmes.



Published in the 9 October edition of The Lancet medical journal, the study predicts that by 2031 – about 50 years into the HIV epidemic – annual new HIV infections will be roughly halved to about 1.2 million. New treatment guidelines recently suggested by the World Health Organization will raise treatment costs by 43 percent.



Costing four HIV prevention and treatment scenarios - including maintaining the status quo - the research estimated that without a cure or vaccine for HIV, as much as US$722 billion might be needed to tackle the virus by 2031 and that a third of this funding would need to be spent in Africa alone.



But according to lead study author Dr Robert Hecht, managing director of the US-based policy NGO Results for Development, costs are not set in stone and could be substantially lower if governments and donors made hard choices now. These would include slowly phasing out aid to middle-income countries that have the resources - but perhaps not the political will - to support programming for their relatively small epidemics among vulnerable groups, such as sex workers, men who have sex with men and injecting drug users.



“One of the surprising things we found was that the price tag [to fund HIV programmes] could vary so significantly from as relatively little as around $400 billion to as much as about $700 billion,” Hecht said. “It really shows you that countries have very different choices to make about how they scale up [HIV prevention and treatment] and the pace at which they do it.”



“Hard choices” described the study’s cheapest scenario in which restricted resources led governments to target vulnerable groups with prevention programmes, and AIDS-related deaths fell below levels associated with current approaches. However, these deaths were still higher than under the most costly scenario - rapid scale-up of prevention and treatment.









''[Some] countries can afford these programmes.  We're not suggesting that the Global Fund pull out now but it's time to start the conversation about the future ''

The study’s ideal scenario, which eliminates structural causes of HIV, including gender inequality, stigma and gender-based violence, would work to reduce HIV risk and might include increasing access to education, reversing laws criminalising HIV and implementing programmes to reduce violence towards women. According to Hecht, structural changes like these would be likely to have spin-off benefits including reduced child mortality and poverty tied to, for instance, increased levels of education among mothers, but would take longer than other senarios to show results.



Implications for aid



The study pointed out that about 20 percent of funding from the Global Fund to Fight AIDS, Tuberculosis and Malaria and the US President’s Emergency Plan for AIDS Relief (PEPFAR) were allocated to middle-income countries. According to Hecht, many of these countries, such as China, Mexico and Kazakhstan, could afford to domestically fund HIV programmes largely targeted at vulnerable populations.



“When the Global Fund began, we didn’t see so clearly the patterns that we see now; we expected explosive epidemics in places like Kazakhstan and Mexico but now we can see that those epidemics aren’t likely to take off. These countries can afford these programmes. We’re not suggesting that the Global Fund and PEPFAR pull out now but it’s time to start the conversation about the future.”



According to Hecht, these conversations should not only include discussion about donors’ exit strategies but should also advance policy agendas that respond to the needs of vulnerable populations that may still experience high levels of stigma and discrimination.



Dependency




But he warned that poor countries with low prevalence rates, such as Vietnam, where HIV funding took up large proportions of health budgets, as well as high-burden, middle-income countries, such as those in southern Africa, would remain dependent on external aid – some for decades to come.



“In [southern Africa], for instance, these countries are relatively better off economically but they really do badly need the external assistance over the next five years at least because they are on a steep part of the cost curve as they catch up with treatment and a backlog in prevention,” he told IRIN/PlusNews.



“These are proud countries that thought that they could finance their HIV programmes with domestic resources but the hard reality is that they need external assistance but if they do all the right things in the next couple of years they could phase out [aid].”



To do this, Hecht said countries such as Botswana, Namibia and South Africa would have to conduct targeted campaigns among vulnerable groups, and scale-up prevention of mother-to-child HIV transmission services, condom distribution and behaviour change communication.



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