Domestic investment in HIV up but uneven

Many sub-Saharan African nations - traditionally the beneficiaries of international HIV funding - are gradually increasing their financial contributions to the fight against the virus, boosting the number of people on treatment to record highs according to a new UNAIDS report, Together We Will End AIDS, released on 18 July.

Low- and middle-income countries invested US$8.6 billion in the response in 2011, an increase of 11 percent compared to 2010, whereas the international community contributed $8.2 billion, a figure that has remained flat since 2008. The United States contributed nearly half of all international assistance for HIV/AIDS.

"This is an era of global solidarity and mutual accountability," Michel Sidibé, executive director of UNAIDS, said in a statement. "Countries most affected by the epidemic are taking ownership and demonstrating leadership in responding to HIV."

Increased local funding

In several African countries, including Kenya, Namibia, Sierra Leone and Uganda, domestic spending on HIV/AIDS rose by more than 100 percent between 2006 and 2011. In Botswana, Comoros, Mauritania, Mauritius, the Seychelles and South Africa, domestic investment accounted for more than 70 percent of AIDS funding.

The increases in funding allowed a record 6.2 million Africans to access life-prolonging antiretroviral treatment in 2011, compared to 5.1 million in 2010. The most impressive numbers in 2011 were seen in South Africa, which initiated 300,000 people on treatment, Zimbabwe (150,000) and Kenya (100,000). The recently released 2012 UN Millennium Development Goals report notes that Botswana, Namibia and Rwanda have achieved universal access to ARVs.

Increased access to ARVs has also helped reduce new HIV infections, with research showing that the medication reduces the transmission risk of people living with HIV. According to UNAIDS, new HIV infections have declined globally by 20 percent since 2011.

Since 2009, new infections in children have fallen by an estimated 24 percent. An estimated 330,000 children were infected with HIV in 2011, about half the number of those newly infected in 2003, the year considered the peak of the epidemic.

But the increased spending has failed to close a large gap in global funding for HIV, estimated to reach $7 billion by 2015, which is significantly short of the $24 billion target set at the 2011 UN High Level Meeting on AIDS. UNAIDS says a "concerted effort by all countries is needed to scale up funding if this target is to be met".

''This is an era of global solidarity and mutual accountability. Countries most affected by the epidemic are taking ownership and demonstrating leadership in responding to HIV''

Not enough

"It is not enough for international assistance to remain stable - it has to increase if we are to meet the 2015 goals," said Sidibé.

In 2011, the Global Fund to Fight AIDS, Tuberculosis and Malaria took the unprecedented decision of cancelling its 11th round of funding after donors failed to meet commitments, denting treatment programmes in many countries.

"Globally we're finally past the half-way mark with HIV treatment, but that still means almost one in two people don't have access to the medicines they need to stay alive. The pace of HIV treatment scale-up and the funding needed to pay for it have both remained virtually stagnant over the last year," Dr Eric Goemaere, senior HIV/TB advisor at the medical NGO, Médecins Sans Frontières in Southern Africa, said in a statement in response to the UNAIDS report. "If we're going to reach all the people who need treatment, we have to double the pace of scale-up and double the funds."

He pointed out that "In places where we work, we see how fragile the progress is that has been achieved over the last decade. Health ministries are working hard to implement the latest treatment recommendations and policies to get ahead of the wave of new infections, but they can't do it alone."

Domestic spending by African governments has been uneven. In Malawi, which has an ambitious plan to put half a million people on ARVs by 2014, the treatment programme is almost entirely donor-funded - the government foots just five percent of its HIV bill - and the country's Global Fund grant comes to an end in 2014.

"The government is committed to fighting HIV, but the economy is not good at the moment and we rely completely on donors. Our programmes are running very well, but without donor support we can't manage on our own," Stuart Chuka, national HIV/AIDS programme officer in Malawi's Ministry of Health, told IRIN/PlusNews.

Need for continued support

"The cost of the ARV programme is almost the same as the total annual national health budget… For our human resources for health, we already have a problem, but with the Global Fund money running out it is going to be quite difficult - the money had helped us hire and retain more workers," he said.

Chuka noted that the country had adopted the latest UN World Health Organization guidelines to switch from the ARV, stavudine, to tenofovir (TDF) in first-line drug regimens, but insufficient resources meant not everyone could be put on the new drug. HIV-positive pregnant women, patients co-infected with HIV and TB, and those with severe reactions to stavudine are being prioritized.

Photo: John Nyaga/IRIN
A record number of sub-Saharan Africans - 6.2 million in 2011 - are now accessing life-prolonging HIV treatment (file photo)

In the Democratic Republic of Congo (DRC), a major World Bank project closed in 2011 after six years, while UNITAID, an international health financing mechanism for paediatric and second-line ARVs, will end its funding to the DRC in December 2012. The US President's Emergency Plan for AIDS Relief (PEPFAR) provides ARVs for prevention of mother-to-child transmission, but only for 18 months, after which patients are expected to be absorbed into the Global Fund's programmes.

The Global Fund - the major donor to DRC's HIV fight - expects to put some 32,000 new patients on ARVs by the end of 2014, but at least 430,000 people need the drugs. Just 12.3 percent of people who need ARVs have access to them, and MSF warns that unless more money is invested, ARV coverage will remain below 25 percent in 2015.

"One of the major problems is delays in seeking treatment - people in the DRC still pay between $15 and $25 for a CD4 test [a measure of immune strength]. At the MSF hospital in Kinshasa we are seeing at least one death per day - 50 percent of these are people who arrived 48 hours earlier - a clear sign of problems in HIV testing," said Thierry Dethier, advocacy officer for MSF in DRC. "Due to the shortage of international support, the government seems afraid to roll out its national testing programme, because it cannot assure HIV-positive patients of treatment."

Agencies working in DRC are hoping to see the government allocate at least $7 million to HIV/AIDS in this year's budget, as well as increased spending on health, which has not exceeded 6 percent of the national budget in the last decade.

"HIV prevention and treatment is needed for all, now and always," said UNAIDS' Sidibé. "I believe that together we will end AIDS. The question is not if, but when."