Donor Government Funding for HIV in Low- and Middle-Income Countries in 2019

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 2019. It is part of a collaborative tracking effort between UNAIDS and KFF 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 30 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 donor governments, UNAIDS, the Global Fund, and UNITAID, and supplemented with data from the DAC. Of the 30 DAC members, 14 provide 98% of total disbursements and individual-level data are provided for each. For the remaining 16 DAC members, data are provided in aggregate. Both bilateral assistance and multilateral contributions to the Global Fund and UNITAID are included (see methodology for more detail).

Findings

Total Funding

Donor funding for HIV through bilateral and multilateral channels totaled US$7.8 billion in current USD in 2019. This represents a decline of US$165 million compared to 2018 (US$8.0 billion) (See Figure 1 and Table 1).1  Even after accounting for inflation and exchange rate fluctuations, funding declined. The decline was largely due to declining disbursements from the United States. Six other governments also had declining disbursements (Canada, Denmark, the European Commission, France, the Netherlands, and Sweden), six increasing (Australia, Germany, Ireland, Italy, Japan, and the U.K.), and one was flat (Norway).2

In 2019, donor governments accounted for approximately 39% (29% was bilateral support and 10% was multilateral support) of the estimated $19.8 billion in resources available to address HIV, according to UNAIDS estimates; domestic resources accounted for 57%, and the remainder was from foundations, other multilateral organizations, and UN agencies. However, UNAIDS also estimates that resources needed by the end of 2020 to reach the global Fast-Track targets including 90-90-90 (90% of people with HIV know their status, 90% of those who know their status are on antiretroviral treatment and 90% of those on treatment are virally suppressed) in low and middle income countries are US$26.2 billion, leaving a gap of several billion dollars, one that has grown in recent years as the number of people living with HIV has increased and the number of new HIV infections remains high.

 

Despite the U.S. decrease in 2019, it remained the largest donor to HIV efforts, providing US$5.7 billion in 2019. The second largest donor was the U.K. (US$646 million), followed by France (US$287 million), the Netherlands (US$213 million), and Germany (US$178 million).

While most funding from donors is provided bilaterally (73%), largely driven by the U.S. (which provides 89% of its funding through bilateral channels), the majority of donors (nine – Australia, Canada, European Commission, France, Germany, Italy, Japan, Norway, and Sweden) provide a larger share of their resources through multilateral channels (See Figure 2).

 

Bilateral Disbursements

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$5.7 billion in 2019, a decline of almost US$300 million compared to 2018. The 2019 decrease was largely due to decreased bilateral disbursements by the U.S. (of US$218 million). Among the factors driving the U.S. decline were a decreasing funding pipeline available as Congressional appropriations for HIV were generally flat as well as the U.S. government shutdown in 2019 which delayed funding disbursements for some time (see Box 1 and Figure 3). In addition to the U.S., six other donor governments decreased bilateral funding in 2019 (Canada, Denmark, the European Commission, the Netherlands, Sweden, and the U.K.), five increased (France, Germany, Ireland, Italy, and Japan) and two remained flat (Australia and Norway). These trends were the same after accounting for inflation and exchange rate fluctuations, with the exceptions of Sweden and Norway, both of which increased funding in currency of origin.3

Box 1: 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. Part of the decline in 2019 was due to a diminished pipeline of available funding as funds from prior years were disbursed in 2017 and 2018 and Congressional appropriations have been flat for the past few years. Other factors contributing to the decline, as reported by PEPFAR, were temporary, and include the 2019 federal government shutdown, which delayed disbursements, as well as staffing shortages that have since been filled. (see Figure 3).

 

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 – have fluctuated over time in part reflecting pledging periods to the Global Fund. In 2019, these contributions totaled $2.1 billion (after adjusting for an HIV share to account for the fact that the Global Fund and UNITAID address other diseases), an increase of US$113 million compared to 2018. Funding was US$1.8 billion for the Global Fund, US$99 million for UNITAID, and US$178 million for UNAIDS. Eight of 14 donors (Australia, Germany, Ireland, Italy, Japan, the Netherlands, the U.K., and the U.S.) increased their multilateral contributions, while five (Canada, France, Norway, Sweden, and the European Commission) decreased, and one remained flat (Denmark). These trends were nearly identical after adjusting for inflation and exchange rate fluctuations, except for France, Norway, and Sweden, which provided essentially flat funding in currency of origin.2,4 It is important to note that during the most recent Global Fund Replenishment Conference, most of the donor governments profiled increased their pledges compared to the prior period.

Recent Funding Trends

After a steep rise in donor government funding for HIV between 2002, the start of new global HIV initiatives, and 2008, the onset of the global financial crisis, funding first plateaued and even fell, and has since fluctuated over much of the last decade. Funding in 2019 was essentially the same as a decade ago, despite an increase in the number of people living with HIV in low- and middle-income countries by 25% over this period. Moreover, without funding from the U.S., funding for HIV from other donor governments would have declined by more than $1 billion since 2010, from US$3.2 billion to US$2.1 billion. Almost the entire decline is attributable to their decreased bilateral support for HIV (from US$1.6 billion in 2010 to US$623 million in 2019). While their multilateral contributions have increased in recent years, they have not been enough to offset overall declines (See Figure 4).

 

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 2019, 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 2018 ($19.8 billion) to their share of the global 5 By this measure, three countries, the U.S., the U.K., and the Netherlands, provided greater shares of total HIV resources than their shares of total GDP (Figure 5). The U.S. provided the greatest share of total resources (29%).
  • 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), putting the U.S. on top, followed by the Netherlands, the U.K., and Sweden (Figure 6).

 

Looking Forward

Funding from donor governments for HIV fell in 2019. While much of this decline can be attributed to decreases by the U.S., donor governments other than the U.S. continued to reduce their bilateral funding for HIV and these declines have not been fully offset by their contributions to multilateral institutions, including the Global Fund. Looking ahead, U.S. funding is not likely to increase as Congressional appropriations have been flat, and the PEPFAR funding pipeline has diminished. Moreover, the impact of the COVID-19 pandemic and the resulting economic crisis, which began in 2020, on the HIV response has yet to be fully realized but will likely put significant pressures on existing budgets as donors struggle to address the crisis within their own borders.

 

Key Findings Methodology