Progress towards ending AIDS as a public health threat has been strongest in the countries and regions with sufficient investments in their HIV responses, especially in countries from eastern and southern Africa. However, a critical part of this success lies in understanding where resources are being allocated and ensuring that investments are directed towards the most impactful interventions.

“HIV financial data is essential for decision-making”, said Jaime Atienza, Director of Equitable Finance at UNAIDS. “This is especially important when we can see constraints, now and around the corner.”

To reflect on the current use and future potential of HIV financial data, UNAIDS and the Global Fund to Fight AIDS, TB and Malaria brought together representatives from 10 African countries to Cape Town, South Africa. During the event, countries shared how they are using HIV financial data to transform their national HIV responses.

In the case of Kenya, for example, the 2022 National AIDS Spending Assessment (NASA) revealed that approximately 84% of the funds for care and treatment programmes came from external sources. This heavy reliance on external funding prompted the development of a cabinet advisory note on local commodity manufacturing, aimed at addressing commodity security risks. In response, the Office of the Presidency issued a statement on Worlds AIDS day 2022 directing that the government would support the pharmaceutical sector to strengthen its local manufacturing capacity and review relevant regulations and tax policies to create an enabling environment.

In Mozambique another NASA study showed how the country spent 26% less on HIV treatment than the National Strategic Plan required, while still surpassing the antiretroviral (ART) coverage target. ART unit costs have fallen from US$ 208 in 2017 to US$ 137 in 2022—well below most countries in the region. Economies of scale and differentiated service delivery likely contributed to this outcome. “We are using this data to inform multi-sectoral plans and state budgets” said Francisco Mbofana, Executive Secretary of Mozambique's National AIDS Council.  

HIV financial data is also seen by countries as an effective tool for mobilizing resources. Ethiopia’s NASA and National Health Accounts (NHA) informed a Domestic Resource Mobilization Strategy. The Strategy aims to boost domestic investment from US$ 27.9 million in 2020 to US$ 68.5 million by 2025 through government revenues, AIDS fund(s), targeted mainstreaming, community care coalitions, and earmarked taxes. In addition, South Africa demonstrated to the Global Fund that of the US$ 6.3 billion the government committed to invest in HIV from 2022-2025, US$ 6.2 billion (98.99%) is likely to be realized. This, in turn, unlocks the US$ 92.7 million co-financing incentive from the Global Fund grant for 2025-2028.

Financial data has also stressed the major underinvestment in HIV prevention. “The de-prioritization of HIV prevention is among the top sustainability threats,” said Thembisile Xulu, Chief Executive Officer of the South African National AIDS Council. While prevention will require a third (32.8%) of total HIV resources by 2025, NASA data shows current HIV prevention spending is at 9.4% in Kenya, 9% in Namibia, 11% in South Africa, and 13% in Uganda.

Nonetheless, several strategies to boost HIV prevention investments are being developed following evidence provided by HIV financial data. Kenya used its NASA data to develop guidelines for harnessing resources from construction projects to support HIV prevention. Zimbabwe’s resource tracking influenced a new policy to implement social contracting with a least one civil society organization per province, to channel domestic resources to community-led HIV responses. Zimbabwe has committed to invest 21% of domestic funds in HIV prevention, with a focus on key populations.

In the current environment of dwindling resources for HIV—2023 recorded the lowest amount of resources available for HIV in low-and-middle income countries in a decade—strengthening HIV resource tracking is key to ensure effective and sustainable HIV responses. “We need to plan for sustainability,” said Nertila Tavanxhi, Senior Manager for Health Financing Country Support at the Global Fund. “To do this, we really need to understand who is funding what, where and whom. This will show us the gaps, and where we must focus.”

“We are in a time of transformations towards sustainability,” said Mr Azcona. The National HIV Response Sustainability Roadmaps are an essential part of the work that the Global Fund, UNAIDS, PEFPAR and country partners are undergoing in 2024 and 2025. “This makes it even more important to have the right data to make the best possible choices on what these transformations must be.” 

During the West and Central Africa Summit on HIV in Dakar, several international partners and ministers gathered to discuss the pressing situation around health financing in the region, exacerbated by the economic crisis due to COVID-19. When it comes to funding HIV responses, WCA is facing a perfect storm: resources available for HIV in the region in 2020 were approximately three quarters of the amount needed. In addition, total HIV resources in the region declined by 11% in the last decade. While PEPFAR and the Global Fund have increased their commitments to the region, domestic resources have slowed down since 2018 and dropped dramatically in 2020.

COVID-19 epidemic did not help. Most African governments have responded to the economic shock by increasing government spending last year however, but with revenues hit by the slow-down, the pandemic will leave many countries with large deficits and unmanageable debts.

Winnie Byanyima, UNAIDS Executive Director, stressed the importance of focusing on these challenges by also re-thinking and reforming overall health systems. She urged countries, as did many other panellists, to use dwindling funds more efficiently, and to ensure additional resources be dedicated to health. “Healthy people means healthy economies,” she said.  She also called for more space to be given urgently to community-led services.

“We need to properly fund community infrastructure and response to be strongly integrated with formal health systems. This is critical as we think about preparing and coping with future pandemics,” Ms Byanyima said.

PEPFAR Deputy Coordinator for Multi-Sector Relations Mamadi Yilla wholeheartedly agreed. "COVID-19 acted like a catalyst and everyone recognized civil society’s role in getting services to the people,” she said. Mentioning that PEPFAR has invested billions in Africa since 2003, she said that the partnerships have to be re-invented and urged governments to work hand in hand with civil society as well as deploy funds in a targeted fashion.

“We have to challenge ourselves to make each dollar count,” said Global Fund Executive Director Peter Sands, "COVID-19 has indeed highlighted the obvious: investing in health makes sense.” He added, “It is important to have finance and economic ministers as part of the answer because health ministers will not be able to solve this on their own.”

Recognizing the need for increased domestic spending on health, the Senegalese Minister of Economy, Planning and Cooperation, Amadou Hott, noted that the current economic slump limits countries' ability to invest more of their resources in the sector. He, like Ms Byanyima, said additional resources must be drawn from debt cancellation, additional international financing mechanisms such as augmenting international liquidity (Special Drawing Rights (SDRS) from the IMF), and fight tax evasion to help increase domestic tax collection.

The Sierra Leone Health Minister, Austin Demby, said that earmarking disease specific resources does not build sustainable health systems, citing an example of a recent measles outbreak in his country. He had to immediately deploy funds to contain it. “We have to create broader platforms to be more flexible,” he said. “Make sure some of the systems around community engagement, and services used every day for HIV, tuberculosis, and malaria can be used for other diseases.”

In addition, financing shouldn’t be tied to specific implementing partners. Both Ministers stressed that to transform health systems, they needed to be given more leeway to implement models that can be self-sustaining on domestic resources, which was not currently the case.

Finally, climate change must be taken into account as it impacts the planet and inevitably people’s wellbeing. The West and Central Africa region, hit hard by desertification and drought, will only feel more pressure on already overwrought health systems.

“Linking funding for climate change and health is crucial because one will inevitably impact the other and increase vulnerabilities to pandemics and diseases,” Mr Hott said in his closing remarks.

Universal access to quality comprehensive sexuality education is crucial, especially for young people. It enables young people to make informed decisions and be empowered as they explore their sexuality and relationships. It helps them acquire the skills and values of mutual respect, tolerance, gender equality and non-violence, and it equips them with the knowledge they need to protect their health and well-being more effectively.

Levels of HIV knowledge vary across countries, depending on the national and local context, and they often are associated with social and economic inequities. In many countries, levels of comprehensive and correct knowledge of HIV among adolescent girls and women are low, but they tend to be lowest among those who live in poverty and those with lower levels of education. They also are lower among rural women than those in urban areas.

The UNAIDS Executive Director, Michel Sidibé, has completed a five-day visit to three countries in southern Africa. The mission included high-level political discussions, the launch of the Lesotho HIV health and situation room and a frank and open dialogue with women activists about how to address sexual harassment and abuse.

Beginning in Lesotho, Mr Sidibé attended the launch of the HIV health and situation room with the Deputy Prime Minister, Monyane Moleleki. Special guest Naomi Campbell was invited by UNAIDS to join the two-day country visit to learn more about the HIV response.

The Lesotho HIV and health situation room shows real-time service delivery data, producing a comprehensive picture and understanding of Lesotho’s HIV epidemic. It enables quick feedback on results at the national and community levels and identifies bottlenecks in access to health-care services.

“The launch of the Lesotho HIV and health situation room gives us access to data to shape impactful and efficient health programmes. These are the kind of innovations that will bring services to those who need them most and ensure that no one is left behind by the AIDS response,” said Michel Sidibé, the UNAIDS Executive Director.

On the eve of the launch, Mr Sidibé and Ms Campbell visited the Queen II Hospital in Maseru, Lesotho, and met with young women living with HIV and others affected by the epidemic.

“I commend the Government of Lesotho and its partners for the progress made in the AIDS response. But the work is far from done. The reality is that we are not reaching adolescent girls and young women. I leave Lesotho today empowered, inspired, encouraged and determined to do all I can to highlight this critical issue,” said Ms Campbell.

In South Africa, Mr Sidibé addressed the Pan African Parliament and underlined the importance of integrated health approaches that were people-centred. He urged parliamentarians to commit more domestic funding for health services to increase the sustainability of the AIDS response and to put in place more preventative measures to improve people’s health. In addition, he called for laws to protect women and vulnerable groups. 

Mr Sidibé left the parliamentary session to meet civil society activists concerned by UNAIDS' response to allegations of sexual harassment and abuse in the organization.

At a follow-up meeting the next day, Mr Sidibé and women activists met to discuss their concerns.

Mr Sidibé agreed with activists to issue a statement following the meeting. The statement begins:

‘During my recent visit to South Africa, I listened carefully to you, I heard you. The HIV epidemic is inextricably linked to sexual and gender-based violence and the two can never be separated. We need the passion of advocates to move issues forward.`

During his visit to South Africa, Mr Sidibé held separate meetings with the President, Cyril Ramaphosa, the Deputy President and South African National AIDS Council Chair, David Mabuza, and the Minister of Health, Aaron Motsoaledi. They discussed plans to increase the number of people on treatment by 2 million by 2020 and the need to empower local and provincial authorities to bring treatment and prevention services closer to vulnerable communities.

The last leg of Mr Sidibé’s visit saw him arrive in Lusaka, Zambia, to confer the 2018 UNAIDS Leadership Award upon Kenneth Kaunda for his efforts in strengthening the AIDS response.  

The Global Review Panel on the Future of the UNAIDS Joint Programme Model has issued its final report, Refining and reinforcing the UNAIDS Joint Programme Model, which offers guidance on ways the Joint Programme can step up efforts to deliver more results for people living with and affected by HIV.

Around 100 participants, representing a wide range of stakeholders, including United Nations Member States, United Nations agencies and civil society, gathered in Geneva, Switzerland, on 28 April to discuss the findings and recommendations of the panel at a global multistakeholder consultation.

The panel validated the vision and model of UNAIDS, recognizing its irreplaceable value in the AIDS ecosystem and underscored its strong foundation of assets—among them, country presence, political legitimacy and UNAIDS’ role as an international standard-bearer for producing data and evidence that is used to drive decision-making.

In its report, the panel recommends that UNAIDS should continue to transfer human and financial resources to the countries most affected by the AIDS epidemic. Other recommendations include reconfiguring United Nations country AIDS teams to be more responsive to the specific nature of the HIV epidemic and to improve accountability, including by engaging a range of stakeholders at all levels in monitoring progress on the AIDS response.

By refining its ways of working, UNAIDS will be better positioned to fulfil its unique mandate of exercising political leadership, providing strategic information and supporting the engagement of countries with other partners, including the Global Fund to Fight AIDS, Tuberculosis and Malaria.

The report details how UNAIDS could further enhance its support to countries in reaching the ambitious Fast-Track Targets by 2020—reducing new HIV infections to fewer than 500 000, reducing AIDS-related deaths to fewer than 500 000 and eliminating HIV-related stigma and discrimination—which were adopted by United Nations Member States at the United Nations General Assembly High-Level Meeting on Ending AIDS in June 2016. The report also recognizes UNAIDS as a model and pathfinder for progress on the implementation of the 2030 Agenda for Sustainable Development and as an innovative joined-up approach at the cutting-edge of United Nations reform.

The Global Review Panel, requested by the UNAIDS Programme Coordinating Board, was set up to make recommendations for a sustainable and fit-for-purpose UNAIDS. It focused on three fundamental pillars of the Joint Programme: financing and accountability, joint working and governance. It was co-convened by Helen Clark, Chair of the United Nations Development Group, and Michel Sidibé, UNAIDS Executive Director. The Panel Co-Chairs were Awa Coll-Seck, Health Minister of Senegal, and Lennarth Hjelmåker, Sweden’s Ambassador for Global Health. It undertook an extensive process of consultations with a wide range of stakeholders, including at the global and country levels. A revised operating model of UNAIDS will be presented at the Programme Coordinating Board meeting in June for consideration and approval, which will take into account the recommendations of the Global Review Panel.

Quotes

Strengthened global political commitment to HIV prevention must be followed by strengthened financial commitment. The successes of the global AIDS response to date have been fuelled by extraordinary investment. The total amount of financial resources for AIDS responses in low- and middle-income countries reached an estimated US$ 19 billion in 2015, double the amount of resources available in 2006. However, international funding for in-country services in 2015 declined for the second year in a row to US$ 8.2 billion—a 7% reduction from the US$ 8.7 billion in 2014. Public and private domestic investment increased by US$ 0.4 billion over the same period, resulting in approximately similar total resource availability in 2014 and 2015.

Available data show that investments in HIV prevention have slightly increased over time in a number of countries. However, more rapid increases in expenditures for HIV treatment translate to a declining trend in the percentage of total resources dedicated for a wide range of prevention services, including the prevention of mother-to-child transmission, reaching about 20% in recent years—short of the commitment made within the 2016 Political Declaration on HIV and AIDS to ensure that financial resources for HIV prevention are adequate and constitute no less than a quarter of AIDS spending globally.