Donor Government Funding for HIV in Low- and Middle-Income Countries in 2017
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 2017. It is part of a collaborative tracking effort between UNAIDS and the Kaiser Family Foundation that began more than 15 years ago, just as new global initiatives were being launched to address the epidemic. The analysis includes data from all members of the Organisation for Economic Co-operation and Development (OECD)’s Development Assistance Committee (DAC), as well as non-DAC members where data are available. Data are collected directly from donors, the Global Fund, and UNITAID, and supplemented with data from the DAC. Fourteen donor governments that account for 98% of total disbursements are profiled in this analysis. Both bilateral assistance and multilateral contributions to the Global Fund and UNITAID are included (see methodology for more detail).
After two years of declines, donor government funding for HIV in low- and middle-income countries increased in 2017, rising to US$8.1 billion in current USD (a US$1.1 billion or 16% increase over 2016), but it is still not back up to its peak in 2014 (see Figure 1 and Table 1). This funding represents 38% of all resources estimated by UNAIDS to be available for HIV in 2017.1 However, the increase was largely due to the timing of U.S. funding and is not expected to continue. In 2017, U.S. disbursements increased by more than US$1 billion primarily due to timing, as it shifted funding appropriated in previous years to 2017 to fully implement DREAMS.2 Because U.S. appropriations have been flat for several years, future disbursements will likely return to prior, lower levels (see Box and Figure 2). In fact, U.S. appropriations for HIV in FY 2018 were again flat.
|BOX: Understanding PEPFAR Funding Trends
PEPFAR, launched in 2003, led to a dramatic scale up of U.S. HIV efforts in low- and middle-income countries. In PEPFAR’s early years, disbursements trailed Congressional appropriations, which had increased steeply with the start of the program. The lag reflected the need to build infrastructure and significantly expand access to antiretroviral therapy in countries where few had access before; in addition, the program maintained a funding pipeline to ensure access to treatment if there were stock-outs or other delays. More recently, with the slowing and even decline in appropriations, PEPFAR shifted funding to later years for the startup of new programs, such as the DREAMS initiative, and to ensure that funds were spent as effectively and judiciously as possible in the context of flat or potentially decreased funding. As a result, funds from prior years were disbursed in 2017, driving the global increase in donor government funding for HIV. Because Congressional appropriations have been flat for several years, this is not expected to continue (see Figure 2).
The U.S. increase more than offset decreases by most other donors. In 2017, 8 of the 14 donor governments profiled disbursed less funding for HIV compared to 2016, while 6 donors, including the U.S, increased. In currency of origin, the pattern was nearly identical. The U.S. remains the largest donor to HIV efforts, providing US$5.9 billion in 2017. The second largest donor was the U.K. (US$744 million), followed by France (US$268 million), the Netherlands (US$203 million), and Germany (US$162 million).
|Table 1: International HIV Assistance from Donor Governments (bilateral & multiateral), 2009-2017 (current USD in millions)|
Most funding is provided bilaterally (78%), including from the two largest donors – the U.S. and the U.K., though several others (Sweden, Norway, Germany, Japan, Italy, France, and Canada) provide a larger share of their resources through multilateral channels (see Figure 3).
Bilateral disbursements for HIV from donor governments – that is, funding disbursed by a donor on behalf of a recipient country or for the specific purpose of addressing HIV – totaled US$6.3 billion in 2017, a net US$849 million increase compared to 2016. The 2017 increase was due almost entirely to increased bilateral disbursements by the U.S. of US$967 million, without which bilateral funding from other donors would have declined by US$118 million. As mentioned above, the U.S. increase is one of timing and is not expected to continue. Most donor governments – 11 of 14 profiled – disbursed less bilateral funding in 2017 compared to 2016, while two donors, in addition to the U.S., increased. These trends were similar after accounting for inflation and exchange rate fluctuations. More generally, bilateral disbursements for HIV by most donor governments have been on the decline for several years.3 While it is possible that some of this decline may be due to increased integration of HIV programming into other subsectors, it is not possible to track this type of shift with currently available data.
Multilateral contributions from donor governments to the Global Fund and UNITAID for HIV – funding disbursed by donor governments to these organizations which in turn use some of that funding for HIV – have fluctuated over time in part reflecting pledging periods to the Global Fund. In 2017, they totaled $1.7 billion (after adjusting for an HIV share), an increase of $287 million compared to 2016; almost all of this was driven by increased Global Fund contributions. Overall, 6 donors increased their multilateral contributions, while 4 decreased and 4 remained flat.
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:
- Rank by share of total donor government funding for HIV: By this measure, the U.S. ranked first in 2017, followed by the U.K., France, and the Netherlands. 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 2017 ($21.3 billion) to their share of the global economy.1 By this measure, 3 countries, the U.S., U.K., and Denmark, provided greater shares of total HIV resources than their shares of total GDP (see Figure 4). The U.S. provided the greatest share of total resources (28%).
- Rank by funding for HIV per US$1 million GDP: After standardizing donor government disbursements by the size of donor economies (GDP per US$1 million), the U.S. ranked at the top for the first time, a reflection of the increased disbursements in 2017; over the past several years, the U.S. has ranked 3 by this measure. It was followed by the U.K., Denmark, and the Netherlands (see Figure 5).
|Table 2: Assessing Fair Share Across Donors, 2017|
|Government||Share of World GDP||Share of Total Donor Government Funding for HIV1||Share of Global Resources Available for HIV2||Total HIV Funding Per $1 Million GDP|
|1 – In 2017, donors provided an estimated $8.1 billion in international assistance (bilateral and multilateral) for HIV in low- and middle-income countries.|
|2 – UNAIDS estimates that US$20.6 billion was available for HIV from all sources (domestic, donor governments, multilaterals, and philanthropic) in 2017, expressed in 2016 USD. For purposes of this analysis, this estimate was converted to 2017 USD, or $21.3 billion.|
|3 – Represents Non-DAC member contributions to the Global Fund and UNITAID. Bilateral HIV funding from these donor governments is not currently available.|
In many ways, 2017 appears to be an outlier for donor government funding of HIV in the current era. While funding increased, following two years of declines, the increase was largely due to unique circumstances in the U.S. that are not likely to continue. If, as expected, U.S. disbursements return to prior levels as Congressional appropriations stay flat, overall funding from donor governments is likely to fall again without additional commitments. At the same time, other donors have faced competing demands for increased refugee and humanitarian aid in recent years, putting their longer-term priorities under pressure.4 This complex set of circumstances suggests that future funding by donor governments for HIV will not bring the global community much closer to reaching the global goal of ending the AIDS epidemic as a public health threat by 2030.Key Findings Methodology