This World AIDS Day on 1 Dec should have been a much more joyous event: the global HIV/AIDS response has turned a significant corner, with record numbers of people on antiretroviral (ARV) treatment and fewer new HIV infections. But the announcement by the Global Fund to Fight AIDS Tuberculosis (TB) and Malaria, cancelling its next funding round, has cast a shadow over any celebrations and highlighted the precarious nature of HIV/AIDS funding.
That money for HIV/AIDS efforts is not as plentiful as in previous years hardly comes as a surprise. UNAIDS notes that the global economic crisis appears to have put an end to a decade of funding increases by donors - after flattening out in 2009 for the first time, international AIDS assistance fell by 10 percent in 2010.
Nandini Oomman, director of the HIV/AIDS Monitor, which tracks AIDS spending at the Washington-based Centre for Global Development, admits that “we are in a bad situation” and faced with “less money and more [health] priorities”. Moreover, non-communicable diseases have overtaken HIV/AIDS as the leading cause of death worldwide. Global and national leaders are now confronted with a “set of tough choices”, she noted.
Zimbabwe’s Minister of Health, Dr Henry Madzorera, believes it is still too early to gauge the full impact of the global funding decline. “We do anticipate that [this] will have a negative impact on our universal access goal… that the consequences of this global economic meltdown will be catastrophic to our programmes… [and] will take us back many years,” he told IRIN/PlusNews.
The big squeeze
As the world’s largest donor to HIV/AIDS efforts, the United States contributes 54 percent of international AIDS financing, but the Centre for Global Development warns that in America’s current political and fiscal climate, this level of support for AIDS funding may have reached a “tipping point” and “will be increasingly difficult to maintain in coming years”.
Oomman pointed out that the US President’s Emergency Plan for AIDS Relief (PEPFAR) was protected by legislation until 2013, so cuts in the funding mechanism may not be as deep as feared. “The real questions [about the future of PEPFAR] will open up in two years, when the US is faced with reauthorizing PEPFAR,” she noted.
In the meantime, the US global AIDS budget has been cut for the second year running - funding for PEPFAR in 2012 will be US$90 million less than the current allocation - and support for the Global Fund has flat-lined.
The cost implications are huge, particularly for countries such as Uganda that rely heavily on PEPFAR. According to Médecins Sans Frontières (MSF), less than half of the people needing treatment in Uganda get it, and PEPFAR currently supports 75 percent of all patients receiving ARVs in the country. International donors are increasingly requesting that Uganda look for domestic funds to support its response.
Although South Africa is better resourced and funds more than 80 percent of its treatment costs, it still receives substantial amounts from foreign donors. PEPFAR’s shift from direct service provision to technical assistance has caused hospices and institutions that were providing ARVs to close down, and patients have been referred to a public health system that is overstretched and poorly equipped to deal with the growing numbers, Nokhwezi Hoboyi, district coordinator for the Treatment Action Campaign, told journalists at a press briefing.
The UK’s Department for International Development (DfID) is also cutting bilateral aid for HIV/AIDS projects in developing countries by 32 percent, from £59.9 million ($92 million) to £41 million ($64million), between now and 2015.
Bailing out of the Fund?
With many donor countries preoccupied with the economic crises on their doorsteps and slowly starting to reduce their HIV/AIDS funding, the Global Fund remains a crucial player despite its latest setback. The amount of money that the multilateral body has made available since it was created in 2001 was “absolutely unprecedented” said Dr Eric Goemaere, head of MSF South Africa’s medical unit.
On 28 November, MSF warned that many low-income countries with a high HIV/AIDS burden were relying heavily on money from the Global Fund to continue providing treatment as well as to scale up their programmes. Some countries have been unable to implement the most recent World Health Organization guidelines, which call for earlier initiation of treatment and better first-line drugs.
The Global Fund has also been hit by a crisis in confidence in recent months, after reports of grant mismanagement found by the Fund’s Office of the Inspector General and the findings of a high-level independent review panel that recommended major changes to its accountability structures.
Oomman told IRIN/PlusNews that rather than “buckling down” to fix the Global Fund model, however, donors were “bailing out” by failing to live up to their commitments. “This doesn’t absolve the Fund of the responsibility to fix itself and reform… but it was created by the donors and should be fixed by the donors,” she commented.
High-burden nations need to do more
With its future at stake, the Global Fund has been encouraging emerging markets to pick up the baton, but the reality is that financial backing from traditional donors such as America and the European countries is still vitally important. “If I were an emerging market government, would I put my money in [an organization] which Western donors are pulling out of?” Oomman asked.
Activists agree that although some countries with high HIV prevalence rates still can’t afford to put a lot of money into their AIDS response, they cannot be completely absolved.
“Sustainability depends on domestic funding. Even in this hard economic environment, countries can at least lay down the enabling instruments that will grow over time and take over from donor funds when these funds dry up,” Zimbabwe’s Madzorera acknowledged.
“African governments are not doing enough at this stage,” he said, “and it cannot be allowed to be ‘business as usual’ in the face of this global economic crisis.”