Funding for Key HIV Commodities in PEPFAR Countries

• In many low- and middle-income countries, PEPFAR and the Global Fund are significant funders of commodities to diagnose, treat, and prevent HIV, along with country governments. But, information on their relative contributions, which is important for assessing the HIV response, is not readily available. We analyzed data from PEPFAR documents on funding for key HIV commodities in 34 PEPFAR countries to better understand the funding landscape.
• Overall, we find that funding for HIV commodities in these countries was estimated to total more than $3 billion among PEPFAR countries required to submit 2019 Country and Regional Operating Plans. Almost two-thirds was for antiretroviral drugs (ARVs) (64% or $1.95 billion), followed by lab and diagnostic products (26% or $779 million). Funding for each of the other commodity types was 6% or less.
• While PEPFAR is the largest funder of HIV efforts in the world, it was not the dominant funder overall for HIV commodities in PEPFAR countries. Country governments were the largest funder of HIV commodities (44% or $1.3 billion), followed by the Global Fund (31%), and PEPFAR (24%). Overall, South Africa’s domestic government funding accounted for 56% of all country government commodity support. When commodity funding for South Africa is removed from the analysis, the Global Fund was the top funder and PEPFAR was second.
• The main funder varied by commodity. For example, PEPFAR accounted for the largest share of funding for voluntary medical male circumcision (VMMC)-related commodities in countries with a VMMC program, and the Global Fund accounted for the largest share of funding for condoms and lubricants. While country governments accounted for the largest overall share of ARV funding, the Global Fund was the top ARV funder when South Africa was removed.
• The main funder also varied somewhat by country. The Global Fund provided the largest share of commodity funding in most PEPFAR countries (21 of 34), followed by country governments (8 of 34) and PEPFAR (5 of 34).
• As we find here, PEPFAR is not the dominant funder of HIV commodities in most of the countries where it works, although PEPFAR often funds many of the associated services needed to support the delivery and use of commodities and, as the main donor to the Global Fund, indirectly funds a larger share of commodities in PEPFAR countries. These findings could help to inform assessments of the sustainability of HIV efforts, decision-making about the most effective division of commodity funding between purchasers, and opportunities for better coordination and synergy in the future, particularly given concerns about overall HIV funding in low- and middle-income countries.

Introduction

Global HIV/AIDS programs depend on having a reliable supply of health commodities, including essential medicines and other products, to prevent, diagnose, and treat HIV. Key commodities in the HIV/AIDS response include: antiretroviral drugs (ARVs), condoms and lubricants, laboratory and diagnostic products (including rapid test kits and viral load commodities), and voluntary medical male circumcision (VMMC) supplies, among others. PEPFAR, along with the Global Fund, to which the U.S. is the largest donor, is a critical source of funding for key commodities, as well as associated services, in low- and middle-income countries (LMICs), sometimes supplementing country government funding or supporting most of a country’s effort.¹  However, information on their relative roles is not readily available. Such data are important for assessing the HIV response, particularly given concerns about overall global funding for HIV, which has declined in recent years.² 

We sought to better understand PEPFAR’s role, relative to the Global Fund and country governments, in directly funding HIV-related commodities in PEPFAR countries (as the largest donor to the Global Fund, PEPFAR indirectly funds a larger share of commodities in the countries in which it works). To do so, we analyzed data from PEPFAR’s 2019 Country and Regional Operating Plan (COP and ROP) Strategic Direction Summaries (SDS) (“COP19”).³  These are documents submitted by PEPFAR country teams, as part of their larger COP/ROP submission, which describe a country’s strategic plan for the coming year, as well as provide a framework for how the country will measure progress. The SDS includes data on funding for commodities by source. We used these data to assess the relative shares of funding by source and by commodity in the 34 countries required to develop a COP or ROP in 2019, and which provided data on commodity funding distribution (an additional 20 countries were required to submit a COP or ROP in 2019 but did not provide these data).⁴  These 34 countries represented 67% of all people living with HIV and over half (approximately 54%) of new infections globally in 2019.⁵ 

Data extraction and cleaning were conducted jointly by KFF and amfAR, and the final dataset is housed on amfAR’s site here. Data were extracted as reported in the 2019 COP/ROP SDS documents, but not validated beyond these sources. In some cases, data were presented in dollar amounts and in others, as percentages of total funding. We computed both percent and dollar values where needed; percent totals may not sum to 100%.⁶  We grouped commodities into six broad categories: ARVs; condoms and lubricants; lab and diagnostic products; other commodities; other drugs; and VMMC products (see Box). All 34 countries provided data on ARVs; 33 for lab diagnostic and products; 29 countries for condoms⁷  and lubricants; 28 for other drugs; 19 for other commodities;⁸  and 13 for VMMC commodities.⁹ 

Key Findings

Funding for HIV commodities in 34 PEPFAR countries was estimated to total more than $3 billion ($3,051,168,558) from all sources in the 2019 COP/ROPs.

• Funding ranged from $709,000 in Tajikistan to $762 million in South Africa (See Figure 1).
• 10 countries accounted for 76% of all funding for commodities.

Almost two-thirds of commodity funding was for ARVs (64%), followed by lab and diagnostic products (26%). Funding for each of the other commodity types was 6% or less. 

• Overall, ARVs accounted for 64% ($1.95 billion) of funding for all commodities in 2019 (See Figure 2). Lab and diagnostic products represented the second largest share (26% or $779 million), followed by other drugs (6% or $177 million), and condoms and lubricants (2% or $59 million).
• ARVs represented the largest share of commodity funding in almost all (29 of the 34) PEPFAR countries included in this analysis (See Figure 3).

While PEPFAR is the largest single funder of HIV efforts in the world, it was not the dominant funder overall for HIV commodities in these 34 countries. Rather, in aggregate, country governments provided the largest share of commodity funding (44%), followed by the Global Fund (31%) and then PEPFAR (24%). Excluding the South Africa program, whose funding accounts for nearly a quarter of total funding for commodities across the 34 countries and almost exclusively from domestic resources, the Global Fund was the top funder and PEPFAR was second.

• Funding from country governments totaled an estimated $1.3 billion (44%), followed by the Global Fund ($935 million or 31%), PEPFAR ($735 million or 24%), and other sources ($39 million or 1.3%) (See Figure 4).
• This is primarily due to the significant role played by the South African government in funding HIV-related commodities. In 2019, the South African government’s commodity contribution ($746 million) accounted for almost all of the country’s commodity funding (98% of $762 million), 56% of total country government commodity funding ($1.3 billion), and nearly a quarter (24%) of funding for all commodities across the 34 countries ($3 billion). With South Africa removed from the analysis, PEPFAR was the second largest funder of commodities ($729 million or 32%), after the Global Fund ($924 million or 40%) (See Figure 5).

The main funder varied by commodity. For example, PEPFAR was the largest funder of VMMC-related commodities in the group of countries with VMMC programs and the Global Fund was the largest of condoms and lubricants. In most cases, though, the order changed when South Africa was removed.

• ARVs. The largest funder of ARVs was country governments, which accounted for 45% of all ARV funding, followed by the Global Fund (33%), PEPFAR (21%), and other sources (<1%) (See Figure 6). With South Africa removed, the Global Fund becomes the largest funder (45%), followed by PEPFAR (29%) (See Figure 7).
• Condoms and Lubricants. The Global Fund was the largest funder of condoms and lubricants (38%), followed by country governments (24%), PEPFAR (22%), and other sources (15%) (see Figure 6). With South Africa removed, PEPFAR was the second largest funder (See Figure 7).
• Lab and Diagnostic Products. Country governments were the largest funder of lab and diagnostic products (44%), followed by PEPFAR (30%), the Global Fund (24%), and other sources (2.5%) (See Figure 6). Without South Africa, PEPFAR moves to the top (See Figure 7).
• VMMC Commodities. Among the 13 countries that reported funding on VMMC commodities,¹⁰  PEPFAR was by far the largest payer of VMMC-related commodities (75%), followed by the Global Fund (19%), and country governments (6%) (See Figure 6). The shares, but not order, of the distribution shifts slightly without South Africa (See Figure 7).
• Other Commodities and Other Drugs. Among the 19 countries that specified funding for other commodities in 2019,¹¹  the Global Fund was the largest funder of other commodities (48%), followed by country governments (27%), PEPFAR (22%), and other sources (3.3%) (See Figure 6). The largest funder of other drugs was country governments (54%), followed by the Global Fund (25%), PEPFAR (19%), and other sources (2.6%) (See Figure 6). (South Africa did not report funding in these areas).

• The Global Fund was the largest funder of commodities in 21 of the 34 countries, followed by country governments (8 of 34), and PEPFAR (5 of 34) (See Figure 8). The Global Fund accounted for more than half of all commodity funding in 15 of the 34 countries.
• The Global Fund also was the largest funder for each commodity type in the majority of countries, with the exception of VMMC commodities, where PEPFAR was the largest funder in most countries that had a VMMC program (See Figures 8 and 9). For example, for ARVs, the Global Fund was the dominant funder in 18 countries and PEPFAR in 7 countries. For lab and diagnostic commodities, the Global Fund was the dominant funder in 18 countries and PEPFAR in 9 countries.

Looking Ahead

HIV-related commodities play a key role in the prevention, diagnosis, and treatment of the disease. As shown above, the commodity landscape varies greatly in PEPFAR countries. This variation is likely due to a range of factors, including the context of local HIV epidemics, the evolution of the HIV response in each country, availability of funding from different sources, and the priorities of funders, including of country governments. Given the lack of a cure or vaccine for HIV and millions of people with or at risk for HIV, the importance of funding currently available commodities will continue for some time but may be more challenging in an environment of flat or declining funding.

While PEPFAR is the single largest HIV funder in the world, as we find here, it is not the dominant funder, at least not directly, of HIV commodities in most of the countries in which it works. Rather, the Global Fund and country governments play the main role. At the same time, PEPFAR often funds many of the associated services (e.g., supply chains, laboratory facilities, and health care personnel) that are needed to support the delivery and use of commodities. In addition, given that PEPFAR is the largest donor to the Global Fund, it plays a more significant indirect role in the Global Fund’s support for commodities in PEPFAR countries. Going forward, these findings could help to inform policymakers, implementers, and others as they make decisions about future directions for the HIV response, including assessments of: the appropriate balance of funding for commodities between PEPFAR and the Global Fund; coordination of commodity procurement and provision at the global and country levels; whether current arrangements are best from a sustainability perspective; and how changes in overall funding for commodities or the current payer mix, might affect continuity of services.

1. KFF, u201cThe U.S. Presidentu2019s Emergency Plan for AIDS Relief (PEPFAR)u201d fact sheet, May 2020. PEPFAR, PEPFAR 2019 Country Operational Plan Guidance for all PEPFAR Countries. ↩︎
2. Global HIV funding in LMICs has been largely flat over the years and declined between 2017 and 2019. KFF. Donor Government Funding for HIV in Low- and Middle-Income Countries in 2019, July 2020. ↩︎
3. Funding totals represent amounts reported in countriesu2019 PEPFAR 2019 COP/ROPs (u201cCOP19u201d) for implementation in FY 2020. All references to 2019 throughout this analysis refer to data presented in 2019 COP/ROP documents. The underlying source of these data varies considerably. In some cases, countries used data from previous years, while in others, the data are a result of planning and negotiations with national stakeholders and the Global Fund. ↩︎
4. Zimbabwe reports total funding need, which includes the percent covered by each funding source as well as the gap in funding. For the purposes of this analysis, we removed the percent gap in funding; consequently, Zimbabweu2019s total expenditure on key commodities is lower than what is reported in its SDS. Eswatini only reports 75% of expenditures for condoms, all of which is supported by PEPFAR. We categorized the remaining 25% as u201cOther Funder,u201d as Eswatiniu2019s SDS states u201cit is not expected that there will be a gap in condom supply because PEPFAR will continue to support the optimization of access to low-cost condoms for clients who can afford to pay for condoms while ensuring that the no-cost condoms are distributed according to mapped need.u201d Nepal only reports 66% of its expenditures for u201cOther Drugs.u201d Given that there were no further details provided about the remaining 33%, the data is considered missing and not included in the analysis. ↩︎
5. UNAIDS. AIDSinfo database, accessed May 2021. ↩︎
6. Countries whose percentage totals do not sum to 100% include Burma, Cambodia, Eswatini, Jamaica, Lesotho, Nepal, Zambia, and Zimbabwe. ↩︎
7. Most PEPFAR countries order condoms through USAIDu2019s Commodity Fund. It is possible that there may be inconsistency among countries on how condoms procured through USAIDu2019s Commodity Fund are accounted for in the SDSs; for instance, some countries may call them PEPFAR-supported procurement and others may categorize them as u201cOther.u201d We interpret the funding amounts reported in the SDSs at face value. PEPFAR, 2019 Country Operational Plan Guidance for all PEPFAR Countries. ↩︎
8. Numerous countries did not report data for u201cOther Commoditiesu201d. In some cases, the lack of data might indicate $0 expenditures. As it was not clear, we assumed that any data denoted by a u201c-u201c or u201cN/Au201d in the SDSs were true u201cN/Au201d and noted it as such in this analysis. We applied this assumption to u201c-u201c and u201cN/Au201d in other categories as well. ↩︎
9. According to the 2019 COP Guidance, PEPFAR concentrates its VMMC programs in 14 priority countries. Also, data for PEPFAR-supported VMMC procedures in these countries for 2019 is included in PEPFARu2019s online Panorama Spotlight Dashboard. Twelve of these countries provided VMMC commodity funding data in their 2019 SDSs; two countries, Kenya and Ethiopia, did not provide data on VMMC commodity funding in their 2019 SDSs. According to Ethiopiau2019s SDS, Ethiopia used non-COP resources for its VMMC program. South Sudan, while not noted as one of the 14 priority countries where PEPFAR concentrated its VMMC efforts in 2019, provided funding data on VMMC in its 2019 COP. We included South Sudanu2019s data as reported in the analysis. ↩︎
10. According to the 2019 COP Guidance, PEPFAR concentrates its VMMC programs in 14 priority countries. Also, data for PEPFAR-supported VMMC procedures in these countries for 2019 is included in PEPFARu2019s online Panorama Spotlight Dashboard. Twelve of these countries provided VMMC commodity funding data in their 2019 SDSs; two countries, Kenya and Ethiopia, did not provide data on VMMC commodity funding in their 2019 SDSs. According to Ethiopiau2019s SDS, Ethiopia used non-COP resources for its VMMC program. South Sudan, while not noted as one of the 14 priority countries where PEPFAR concentrated its VMMC efforts in 2019, provided funding data on VMMC in its 2019 COP. We included South Sudanu2019s data as reported in the analysis. ↩︎
11. Numerous countries did not report data for u201cOther Commoditiesu201d. In some cases, the lack of data might indicate $0 expenditures. As it was not clear, we assumed that any data denoted by a u201c-u201c or u201cN/Au201d in the SDSs were true u201cN/Au201d and noted it as such in this analysis. We applied this assumption to u201c-u201c and u201cN/Au201d in other categories as well. ↩︎