Donor Government Funding for HIV in Low- and Middle-Income Countries in 2022

This report provides an analysis of donor government funding to address the HIV response in low- and middle-income countries in 2022, the latest year available, as well as trends over time. It includes both bilateral funding from donors and their contributions to the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), UNITAID, and UNAIDS. Overall, the analysis shows that while donor government funding for HIV increased between 2021 and 2022, this was primarily due to the timing of payments from the U.S. government and not actual increases in commitments. More broadly, UNAIDS reports that total global resources for HIV – including domestic funding – declined slightly in 2022 and are well below the estimated US$29.3 billion needed by 2025 to reach global goals; donor governments account for more than a third of total HIV resources. In addition, while there has been significant progress in addressing the HIV epidemic, new infections and AIDS-related deaths are on the rise in some regions and more than 9 million people living with HIV still lack access to antiretroviral therapy.¹  With continued pressures on domestic and international resources resulting from the war in Ukraine, economic stress, and other challenges, future support for HIV remains uncertain. Key findings include the following:

• Donor government funding for HIV increased in 2022 compared to the prior year. Disbursements were US$8.2 billion in 2022, an increase of more than US$700 million compared to 2021 (US$7.5 billion), in current U.S. dollars (funding increased even after accounting for inflation and exchange rate fluctuations).²  This increase essentially returns funding to 2020 levels in nominal terms, after a decline last year. More broadly, the real value of funding has fallen over the past decade due to the effects of inflation.
• However, the increase in 2022 was primarily due to the timing of U.S. disbursements, rather than increased commitments. S. funding totaled US$6.1 billion in 2022, almost US$600 million above 2021 (US$5.5 billion), and included increases in both bilateral disbursements as well as contributions to the Global Fund.³  These increases, however, were entirely due to the timing of disbursements of prior-year funding rather than increased commitments, as the funding amounts specified by the U.S. Congress for both bilateral HIV programs and the Global Fund have been relatively flat through 2022.⁴  Similarly, while funding from all other donor governments also increased in 2022, this was largely attributable to the timing of Global Fund contributions from France and the European Commission.
• The U.S. continues to be the largest donor to HIV, even after adjusting for the size of its economy. In 2022, the U.S. disbursed US$6.1 billion, accounting for 74% of total donor government HIV funding (bilateral and multilateral combined).⁵  France was the second largest donor (US$382 million, 5%), followed by the U.K. (US$376 million, 5%), the European Commission (US$328 million, 4%), and Germany (US$191 million, 2%). The U.S. also ranked first when standardized by the size of its economy, followed by the Netherlands, France, Sweden, and Denmark.
• Looking at the longer-term trend, funding is below historical levels, largely due to declines in bilateral funding from donor governments other than the U.S. Total bilateral funding from other donor governments has decreased each year for more than a decade (by almost US$1.4 billion or 80% since 2011). While increases in multilateral funding have offset these declines in some years, overall funding is still more than US$1.0 billion below where it was just over a decade ago. This also suggests that the already significant dependency of international HIV resources on the U.S. could grow.
• Taken together, this means that the donor government funding pie, which accounts for more than a third of all global HIV resources, is not growing. Rather, funding has fluctuated for several years, with year-to-year changes largely due to the normal ebb and flow of payment timing and Global Fund pledging periods, but not increasing government commitments to HIV; in fact, current levels are below the high-water mark reached almost a decade ago (US$8.6 billion in 2014). As donor governments continue to face budgetary pressures ranging from ongoing inflation as well the economic impacts associated with the war in Ukraine, increased funding for HIV moving forward is uncertain.⁶  While donor pledges for the Global Fund’s 2023-2025 replenishment period reached their highest level to date, indicating that increased resources may be available in the future, this will be dependent on donor fulfillment of their pledges amid these ongoing constraints. More broadly, UNAIDS reports that funding for the global HIV response from all sources declined in the last year, driven by decreased funding from domestic governments who are facing significant economic pressures, making the gap between available resources and projected need even greater.⁷ 

Introduction

This report provides the latest data on donor government resources available to address HIV in low- and middle-income countries, reporting on disbursements made in 2022. It is part of a collaborative tracking effort between UNAIDS and KFF that began almost 20 years ago, just as new global initiatives were being launched to address the epidemic. The analysis includes data from all 31 members of the Organisation for Economic Co-operation and Development (OECD)’s Development Assistance Committee (DAC), as well as non-DAC members who report data to the DAC. Data are collected directly from donor governments, UNAIDS, the Global Fund, and UNITAID, and supplemented with data from the DAC. Of the 31 DAC members, 14 provide 99% of total disbursements and individual-level data are provided for each. For the remaining 17 DAC members, data are provided in aggregate. Both bilateral and multilateral assistance are included (see methodology for more detail).

Findings

Total Funding

In 2022, donor government funding for HIV through bilateral and multilateral channels totaled US$8.2 billion in current USD, an increase of more than US$700 million compared to 2021 (US$7.5 billion) (See Figure 1 and Table 1).⁸  However, this increase was largely due to the timing of disbursements, particularly for the U.S. (see below), and was not an actual increase in commitments. Total funding in 2022 was essentially a return to prior year levels following a significant decline in 2021, which was similarly due to the timing of disbursements.⁹ 

In 2022, donor governments accounted for approximately 37% of the US$22.4 billion estimated by UNAIDS to be available to address HIV (the total is US$20.8 billion when measured in 2019 constant USD); domestic resources accounted for 60%, and the remainder was from foundations, other multilateral organizations, and UN agencies.^10 ,11 ,12  This amount is well below the US$29.3 billion that UNAIDS estimates will be needed by 2025 in order to reach global goals.¹³ 

The U.S. continued to be the largest donor to HIV efforts, providing US$6.1 billion and accounting for 74% of total donor government funding in 2022.¹⁴  The second largest donor was France (US$382 million, 5%), followed by the U.K. (US$376 million, 5%), the European Commission (US$328 million, 4%), and Germany (US$191 million, 2%). In 2022, 90% of total donor government funding for HIV was provided by these five donors.

While most funding from donors is provided bilaterally (68%), largely driven by the U.S. (which provided 87% of its funding through bilateral channels), the majority of donors (eleven – Australia, Canada, European Commission, France, Germany, Ireland, Italy, Japan, Norway, Sweden, and the U.K.) provide a larger share of their resources through multilateral channels (See Figure 2). Over the past decade there has been a significant shift in how donor governments, other than the U.S., direct their funding, falling from 54% provided through bilateral channels in 2011 to only 16% in 2022 (see below).

Bilateral Disbursements

Bilateral disbursements for HIV from donor governments – that is, funding disbursed by a donor on behalf of a recipient country or region – totaled US$5.6 billion in 2022, an increase of almost US$130 million compared to 2021 (US$5.5 billion). This increase, however, was almost entirely due to the U.S. as bilateral funding from most donor governments either decreased or remained essentially flat in 2022; Denmark and France were the only other donor governments that increased bilateral support (See Figure 3). These trends were the same after accounting for inflation and exchange rate fluctuations except for the U.K., which was flat when measured in currency of origin.

While U.S. bilateral disbursements increased by more than US$200 million in 2022 (US$5.3 billion) compared to 2021 (US$5.1 billion) (See Figure 4), the change was due to the timing of disbursements of prior year funding and was not an actual increase in commitments. In fact, bilateral HIV funding as specified by the U.S. Congress in annual appropriations has been flat for several years.

When the U.S. increase is removed, bilateral funding from all other donor governments decreased by almost US$90 million in 2022 continuing a more than decade-long trend of declining bilateral support. Since 2011, funding from donor governments, other than the U.S., has decreased by almost US$1.4 billion (80%), declines which have not been fully offset by increases in multilateral contributions (See Figure 5 and “Multilateral Contributions” below). As a result, the U.S., which has historically provided the majority of bilateral resources from donor governments, has accounted for an increasing share, rising from 70% in 2011 to 94% in 2022.

Multilateral Contributions

Multilateral contributions from donor governments to the Global Fund, UNITAID, and UNAIDS for HIV – funding disbursed by donor governments to these organizations which in turn use some (Global Fund and UNITAID) or all (UNAIDS) of that funding for HIV – totaled US$2.6 billion in 2022 (after adjusting for an HIV share to account for the fact that the Global Fund and UNITAID address other diseases).¹⁵  Funding was US$2.4 billion for the Global Fund, US$58 million for UNITAID, and US$160 million for UNAIDS.

Donor government contributions to multilateral organizations increased by almost US$600 million in 2022 (US$2.6 billion) compared to the 2021 level (US$2.0 billion), largely due to the timing of contributions to the Global Fund by the U.S., France, and the European Commission. Timing of U.S. contributions to the Global Fund are based in large part on the amount of funding received from other donors, as the U.S. is required by law not to exceed 33% of total contributions to the Global Fund from all donors. For many of the other donor governments, Global Fund contributions tend to fluctuate over the Global Fund’s three-year pledge periods, with some donors providing significant contributions at the beginning of the period, resulting in declines in subsequent years, while others choose to fulfill pledges towards the end of the pledge period, resulting in what appears to be significant increases. For example, in 2022, the European Commission provided a large portion of its pledge for the Global Fund’s 2023-2025 replenishment period. Conversely, the increase in 2022 by France was towards fulfillment of its pledge for the 2020-2022 replenishment period as it provided smaller contributions in the preceding years.

Fair Share

We looked at several different measures for assessing the relative contributions of donor governments, or “fair share”, to HIV. These include: rank by share of total donor government disbursements for HIV; rank by share of total resources available for HIV compared to share of the global economy; and rank by funding for HIV per US$1 million GDP. As shown in Table 2, each measure yields varying results, though the U.S. ranks #1 across all three:

• Rank by share of total donor government funding for HIV: By this measure, the U.S. ranked first in 2021, followed by France, the U.K., European Commission, and Germany. The U.S. has consistently ranked #1 in absolute funding amounts.
• Rank by share of total resources available for HIV compared to share of the global economy (as measured by GDP): This measure compares donor government shares of total resources estimated to be available for HIV in 2022 ($22.4 billion) to their share of the global By this measure, only one country, the U.S., provided a greater share of total HIV resources than its share of total GDP (Figure 6).
• Rank by funding for HIV per US$1 million GDP: Another way of looking at the relationship between HIV donor funding and GDP is to standardize donor government disbursements by the size of donor economies (GDP per US$1 million). This also puts the U.S. on top, followed by the Netherlands, France, and Sweden. (Figure 7)

Looking Forward

As this report finds, the donor government funding pie, which accounts for more than a third of all global HIV resources annually to low- and middle-income countries, has not been growing; rather, funding has fluctuated for several years, with year-to-year changes largely due to the normal ebb and flow of payment timing and Global Fund pledging periods. In fact, current levels are below the high-water mark of almost a decade ago due to decreasing bilateral support from donor governments other than the U.S. As a result of these trends, five donor governments (U.S., France, U.K., Germany, and European Commission) now account for 90% of total donor government funding.  Moreover, while there has been significant progress in addressing the HIV epidemic —there were 1.3 million new infections in 2022, down from approximately 2 million a decade ago, and almost half as many AIDS-related deaths—new infections and AIDS-related deaths are on the rise in some regions, including in Eastern Europe and Central Asia and the Middle East and North Africa. Further, more than 9 million people living with HIV still lack access to antiretroviral therapy.¹⁶ 

Looking ahead, if these trends continue, the financing outlook for 2023 and beyond will likely be dependent on fulfillment of pledges to the Global Fund for the 2023-2025 replenishment period, which was the highest ever and included significant increases from many donors. Notably, for the first time in many years, the U.S. increased its Global Fund pledged commitment to $6 billion over 3 years ($2 billion/year), or a more than $400 million increase per year. This resulted in a $2 billion appropriation by the U.S. Congress for the Global Fund in 2023. However, the extent to which this full amount can be provided will depend on funding from other donors, as the U.S. is required by law not to exceed 33% of total contributions to the Global Fund from all sources. As such, future U.S. funding commitments to the Global Fund could be reduced. These trends and questions moving forward, combined with continued stresses on domestic government budgets, create an uncertain future.

This project represents a collaboration between the Joint United Nations Programme on HIV/AIDS (UNAIDS) and KFF. Data provided in this report were collected and analyzed by UNAIDS and the KFF.

Bilateral and multilateral data on donor government assistance for HIV in low- and middle-income countries were collected from multiple sources for the 31 members of the OECD Development Assistance Committee (DAC). Data are collected directly from donor governments, UNAIDS, the Global Fund, and UNITAID, and supplemented with data from the DAC. The research team solicited bilateral assistance data directly, from the governments of Australia, Canada, Denmark, France, Germany, Ireland, Japan, the Netherlands, Norway, Sweden, the United Kingdom, and the United States during the first half of 2023, representing the fiscal year 2022 period.^17 ,18 ,19  Direct data collection from these donors was desirable because the latest official statistics on international HIV specific assistance – from the Organisation for Economic Co-operation and Development (OECD) Creditor Reporting System (CRS) (see: http://www.oecd.org/dac/stats/data) – are from 2021 and do not include all forms of international assistance (e.g., certain funding streams provided by donors, such as HIV components of mixed-purpose grants to non-governmental organizations).

Where donor governments were members of the European Union (EU), the research team ensured that no double-counting of funds occurred between EU Member State reported amounts and European Commission (EC) reported amounts for international HIV assistance. Figures obtained directly using this approach should be considered as the upper bound estimation of financial flows in support of HIV-related activities.

Data for all other member governments of the OECD DAC – Austria, Belgium, the Czech Republic, the European Commission, Finland, Greece, Hungary, Iceland, Italy, Korea, Luxembourg, New Zealand, Poland, Portugal, the Slovak Republic, Slovenia, Spain, Switzerland – were obtained from the OECD CRS database and UNAIDS records of core contributions. The CRS data are from calendar year 2021, and therefore, do not necessarily reflect 2022 calendar year amounts. However, collectively, these governments have accounted for less than 5 percent of bilateral disbursements in each of the past several years. UNAIDS core contributions reflect 2022 amounts.

Data included in this report represent funding assistance for HIV prevention, care, treatment and support activities, but do not include funding for international HIV research conducted in donor countries (which is not considered in estimates of resource needs for service delivery of HIV-related activities).

Bilateral funding is defined as any earmarked (HIV-designated) amount, including earmarked non-core (“multi-bi”) contributions to multilateral organizations, such as UNAIDS. Reflecting deliberate strategies of integrating HIV activities into other activity sectors, some donors use policy markers to attribute portions of mixed-purpose projects to HIV. This is done, for example, by the Netherlands and the U.K. The bilateral figures submitted by the UK Foreign, Commonwealth & Development Office (FCDO) for the financial year 2022/23 are based on an existing FCDO ‘HIV policy marker’. Ireland and Denmark also attribute percentages of multipurpose projects to HIV. Canada breaks its mixed-purpose projects into components by percentage. Germany, Norway, and Sweden provided data much more conservatively, consistent with DAC constructs and purpose codes. Apart from targeted HIV/AIDS programs, bilateral health programs mainly focusing on health systems strengthening are also designed to contribute to the HIV response in partner countries. Global Fund contributions from all governments correspond to amounts received by the Fund during the 2022 calendar year, regardless of which contributor’s fiscal year such disbursements pertain to. Data from the U.K., Canada, Australia, Denmark, France, Norway, and Germany should be considered preliminary estimates.

Bilateral assistance data were collected for disbursements. A disbursement is the actual release of funds to, or the purchase of goods or services for, a recipient. Disbursements in any given year may include disbursements of funds committed in prior years and in some cases, not all funds committed during a government fiscal year are disbursed in that year. In addition, a disbursement by a government does not necessarily mean that the funds were provided to a country or other intended end-user.

Included in multilateral funding were core contributions to UNAIDS, as well as contributions to the Global Fund (see: http://www.theglobalfund.org/en/) and UNITAID (see: http://www.unitaid.org/#end). All Global Fund contributions were adjusted to represent 52% of the donor’s core contribution, reflecting the Fund’s reported grant approvals for HIV-related projects to date and includes HIV/TB. UNITAID contributions were adjusted to represent 46% of the donor’s core contribution, reflecting UNITAID’s reported attribution for HIV-related projects.

In addition to contributions supporting the Global Fund’s and UNITAID’s core activities, some donor governments provided significant funding to these multilateral organizations for COVID-related efforts. These COVID-specific contributions were not included in totals for the purposes of this report. The U.S., for example, provided almost $1.9 billion in such funding to the Global Fund during 2022.

Other than contributions provided by governments to the Global Fund and UNITAID, un-earmarked general contributions to United Nations entities, most of which are membership contributions set by treaty or other formal agreement (e.g., the World Bank’s International Development Association or United Nations country membership assessments), are not identified as part of a donor government’s HIV assistance even if the multilateral organization in turn directs some of these funds to HIV. Rather, these would be considered as HIV funding provided by the multilateral organization, as in the case of the World Bank’s efforts, and are not considered for purposes of this report.

Bilateral data collected directly from the Australian, Canadian, Japanese, U.K., and U.S. governments reflect the fiscal year (FY) period as defined by the donor, which varies by country. The U.S. fiscal year runs from October 1-September 30. The fiscal years for Canada, Japan, and the U.K. are April 1-March 31. The Australian fiscal year runs from July 1-June 30. The European Commission, Denmark, France, Germany, Italy, Ireland, the Netherlands, Norway, and Sweden use the calendar year. The OECD uses the calendar year, so data collected from the CRS for other donor governments reflect January 1-December 31. Most UN agencies use the calendar year and their budgets are biennial. The Global Fund’s fiscal year is also the calendar year.

All data are expressed in current US dollars (USD), unless otherwise noted. Where data were provided by governments in their currencies, they were adjusted by average daily exchange rates to obtain a USD equivalent, based on foreign exchange rate historical data available from the U.S. Federal Reserve (see: http://www.federalreserve.gov/) or the OECD. Data obtained from UNITAID were already adjusted to represent a USD equivalent based on date of receipts. Data on gross domestic product (GDP) were obtained from the International Monetary Fund’s World Economic Outlook Database and represent current price data for 2022 (see: https://www.imf.org/en/Publications/WEO/weo-database/2023/April).

See here.

1. UNAIDS, “Global AIDS Update Report”, July 2023. ↩︎
2. In 2022, some donor governments provided COVID-specific emergency contributions to the Global Fund and UNITAID in addition to their contributions for core activities. Specifically, Canada, France, Germany, and Japan provided COVID-specific funding to UNITAID, while the European Commission, Germany, the Netherlands, New Zealand, Portugal, the U.K., and the U.S. provided COVID-specific funding to the Global Fund. For the purposes of this report, these COVID-specific amounts have been excluded as they cannot be attributed to a specific area, such as HIV. ↩︎
3. Donor government contributions to the Global Fund and UNITAID have been adjusted for an HIV-share to account for the fact that these multilateral organizations address other diseases and areas (see Methodology). ↩︎
4. U.S. totals represent funding amounts provided through regular appropriations only. In 2021, the U.S. Congress appropriated additional emergency supplemental funding for bilateral HIV activities and for the Global Fund to address the impacts of the COVID-19 pandemic. These emergency supplemental funding amounts are not included in overall U.S. totals. ↩︎
5. In addition to the $5.5 billion disbursed for HIV in 2021 (provided through regular appropriations for bilateral programs as well as the HIV-adjusted share of contributions to the Global Fund and UNAIDS), the U.S. disbursed an additional $4.3 million for bilateral HIV activities from emergency supplemental funding that was provided in response to the COVID-19 pandemic through the “American Rescue Plan Act of 2021” (see KFF analysis of “Global Funding Across U.S. COVID-19 Supplemental Funding Bills”). ↩︎
6. Per direct communication with Swedish International Development Cooperation Agency (SIDA): “Swedish SRHR aid fell by 16% in between 2021 and 2022. This was the result of a reprioritization in the state budget following Russia’s invasion of Ukraine.” ↩︎
7. UNAIDS, “Global AIDS Update Report”, July 2023. ↩︎
8. Donor government disbursements are a subset of overall international assistance for HIV in low-and-middle-income countries, which also includes funding provided by other multilateral institutions, UN agencies, and foundations. ↩︎
9. KFF & UNAIDS, “Donor Government Funding for HIV in Low- and Middle-Income Countries in 2022”, July 2022. ↩︎
10. UNAIDS, “Global AIDS Update Report”, July 2023. ↩︎
11. UNAIDS estimates that US$20.8 billion was available for HIV from all sources (domestic resources, donor governments, multilaterals, and philanthropic organizations) in 2022, expressed in 2019 USD. For purposes of this analysis, this estimate was converted to 2022 USD, or $22.4 billion. In addition, while the amounts presented in this analysis include donor contributions to multilateral organizations, the UNAIDS estimate of total available resources for HIV includes the actual disbursements made by multilateral organizations in 2021 rather than the donor government contributions to these entities. ↩︎
12. The donor share of total available resources includes bilateral disbursements as well as an adjusted share of Global Fund and UNITAID disbursements (the donor government share of contributions to each of the multilaterals in 2021 is applied to the disbursements from these multilaterals for the same year). ↩︎
13. The UNAIDS resource needs estimate is expressed in 2019 USD. ↩︎
14. In addition to the $5.5 billion disbursed for HIV in 2021 (provided through regular appropriations for bilateral programs as well as the HIV-adjusted share of contributions to the Global Fund and UNAIDS), the U.S. disbursed an additional $4.3 million for bilateral HIV activities from emergency supplemental funding that was provided in response to the COVID-19 pandemic through the “American Rescue Plan Act of 2021” (see KFF analysis of “Global Funding Across U.S. COVID-19 Supplemental Funding Bills”). ↩︎
15. In 2022, 54% of the Global Fund’s disbursements and 46% of UNITAID’s disbursements were directed to HIV activities. These percentages were applied to the full donor government contributions to these multilateral organizations to calculate the “HIV-share” (see Methodology for additional details). ↩︎
16. UNAIDS, “Global AIDS Update Report”, July 2023. ↩︎
17. Per direct communication with the German Agency for International Cooperation (GIZ): “In general, Germany supports systemic approaches such as the One Health approach and health systems strengthening through both multilateral and bilateral engagement. In addition to supporting a smaller number of projects that address individual diseases, Germany takes a horizontal, systemic approach by supporting health systems strengthening in general. Efficient health systems are a prerequisite for realizing the human right to the ‘highest attainable standard of physical and mental health.’ Strengthening health systems is therefore the overarching approach to the strategy of German development cooperation in the health sector and is prioritized over funding activities that address individual diseases.” ↩︎
18. Per direct communication with Ireland Department of Foreign Affairs: “The data for 2022, which shows a decrease against 2021 expenditure, is a result of a revised assessment methodology of estimated HIV/AIDS expenditure.” ↩︎
19. Per direct communication with the U.K. Foreign, Commonwealth & Development Office (FCDO): “The FCDO Annual Report and Accounts 2021 to 2022 explained that the department’s ODA spending plans needed to be revisited to ensure all ODA-eligible spending was managed within 0.5% of GNI. This was in the context of the significant and unexpected costs incurred to support the people of Ukraine and Afghanistan escape oppression and conflict and find refuge in the UK, alongside wider migration pressures. We remain committed to protecting the most vulnerable and returning to spending 0.7% of GNI on ODA as soon as the fiscal situation allows.  The FCDO’s latest estimate of its ODA spending for 2022-23 is £7,572m. The FCDO’s indicative ODA budget for 2023-24 is £8,095m. FCDO ODA allocations for these years are set out in the Minister for Development’s 30 March Written Ministerial Statement.” ↩︎