Elsevier

The Lancet

Volume 376, Issue 9748, 9–15 October 2010, Pages 1254-1260
The Lancet

Review
Financing of HIV/AIDS programme scale-up in low-income and middle-income countries, 2009–31

https://doi.org/10.1016/S0140-6736(10)61255-XGet rights and content

Summary

As the global HIV/AIDS pandemic nears the end of its third decade, the challenges of efficient mobilisation of funds and management of resources are increasingly prominent. The aids2031 project modelled long-term funding needs for HIV/AIDS in developing countries with a range of scenarios and substantial variation in costs: ranging from US$397 to $722 billion globally between 2009 and 2031, depending on policy choices adopted by governments and donors. We examine what these figures mean for individual developing countries, and estimate the proportion of HIV/AIDS funding that they and donors will provide. Scenarios for expanded HIV/AIDS prevention, treatment, and mitigation were analysed for 15 representative countries. We suggest that countries will move in increasingly divergent directions over the next 20 years; middle-income countries with a low burden of HIV/AIDS will gradually be able to take on the modest costs of their HIV/AIDS response, whereas low-income countries with a high burden of disease will remain reliant upon external support for their rapidly expanding costs. A small but important group of middle-income countries with a high prevalence of HIV/AIDS (eg, South Africa) form a third category, in which rapid scale-up in the short term, matched by outside funds, could be phased down within 10 years assuming strategic investments are made for prevention and efficiency gains are made in treatment.

Introduction

Overall spending on HIV/AIDS in low-income and middle-income countries increased from around US$1·4 billion in 2000 to $13·7 billion in 2008.1 This rapid and unprecedented expansion has led to many important gains. More than 4 million people with HIV-1 infection are now receiving life-saving antiretroviral therapy (ART).2 Globally, the incidence of HIV infection has reduced 30% from a peak in the mid-1990s.3 Some countries, such as Cambodia, Dominican Republic, Tanzania, and Uganda, have seen substantial declines in incidence.4

Despite these gains, additional large increases in spending for prevention and treatment of HIV will be needed to control the epidemic in the future. Without a revolutionary prevention technology such as an effective vaccine or a curative drug therapy, effective prevention methods such as male circumcision, condom use, needle exchange, and prevention of mother-to-child transmission need to be expanded further, requiring increased financial outlays.

At the same time, demand for ART for adults and children with HIV infection will continue to grow rapidly. In 2009, a million extra people received ART, but 5·5 million of 9·5 million people in need of treatment worldwide did not.2 Furthermore, because the 2009 WHO guidelines recommend earlier initiation of ART, the number of people classified as in need of treatment will increase by almost half.5

The intensifying situation raises a series of difficult questions for domestic and international financing of HIV/AIDS efforts. HIV/AIDS is a long-term problem and not a short-term crisis. Key long-term financing issues for governments of low-income and middle-income countries and their external funder partners include: how large will the resource requirements be to combat HIV/AIDS effectively over the next 20 years, globally and for countries? Given the range of imaginable scale-up scenarios, will countries succeed in controlling their epidemics, and what benefits will they get from increased spending, as measured by infections averted and lives saved? What share of the funding will individual developing countries be able to contribute, and what can be expected from external donor agencies?

Some responses to these questions at the global scale have been reported by the aids2031 project,6 but country-by-country estimates have not been made. We briefly discuss global results and examine the long-term cost of HIV/AIDS and financing prospects for selected countries.

Section snippets

Global results

In 2009, the aids2031 costs and financing working group modelled the long-term financial requirements for strengthening of prevention, treatment, mitigation, and related health systems for all low-income and middle-income countries in 2009–31.7 Financial needs were projected with four scenarios (current trends, rapid scale-up, hard choices, and structural change) with various assumptions about future political will, available resources, and strategic approaches. The four scenarios encompass a

Country projections

Global modelling projections can help us to understand the persisting nature of the HIV/AIDS epidemic and the need for action, including targeted prevention that is rapidly scalable and cheap, and renewed efforts to find improved prevention technologies such as pre-exposure prophylaxis, microbicides, vaccine, or cure. However, some of the most striking outcomes of aids2031 were the projections for individual countries. The global pandemic is heterogeneous, with different subepidemics occurring

Policy options for HBLI countries

Policy makers need to understand the effects of diverging scenarios for HIV/AIDS costs and financing. Despite presently receiving much external financing from the Global Fund, PEPFAR, and other bilateral donors, HBLI countries will find it difficult to meet the increased financial demands of rapidly expanding HIV/AIDS programmes over the next 5–8 years (ie, the economic crunch). For example, the number of people receiving ART in Kenya and Zambia has risen from from 1121 and 10 000,

Policy options for middle-income countries

For the cluster of middle-income countries in southern African with a high burden of disease, HIV/AIDS spending requirements over the next few years will probably rise faster than domestic resources alone can accommodate, even with strong political commitments to HIV/AIDS. External financing might be needed to help to fill the gap. In the long term, however, South Africa, Botswana, Namibia, and Swaziland could move toward financial self-sufficiency as their domestic economies resume growth. A

Conclusions

An important lesson from the aids2031 project is that everyone who is working to combat HIV/AIDS (governments, civil society, donors, and others) needs to focus on long-term trends and outcomes if we are to adopt the best policies today. Since the mid-1990s, we have often been preoccupied with the legitimate short-term challenges of achievement of large-scale political, social, and financial mobilisation and rapid expansion of HIV/AIDS treatment. This work has yielded impressive results.

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