Donor Government Funding for HIV in Low- and Middle-Income Countries in 2020

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 2020. It is part of a collaborative tracking effort between UNAIDS and the 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 and multilateral assistance are included (see methodology for more detail).

Findings

Total Funding

In 2020, when the world was wrestling with the health and economic impacts of the COVID-19 pandemic, donor government funding for HIV through bilateral and multilateral channels totaled US$8.2 billion in current USD, an increase of US$377 million compared to 2019 (US$7.8 billion) (See Figure 1 and Table 1).1 Even after accounting for inflation and exchange rate fluctuations, funding increased. However, the rise in 2020 was almost entirely due to the timing of contributions to the Global Fund from the U.S., without which, overall funding would have declined. In fact, total funding from most donor governments (10 of the 14) declined in 2020, with the exception of Germany, Japan, and the U.S., which increased, and Italy, which remained essentially flat.

According to UNAIDS estimates, donor governments accounted for approximately 37% of the estimated $21.7 billion in resources available to address HIV in 2020; domestic resources accounted for 61%, and the remainder was from foundations, other multilateral organizations, and UN agencies.2 This amount is well below the US$29 billion that UNAIDS estimates will be needed by 2025 in order to reach global goals.

The U.S. continued to be the largest donor to HIV efforts, providing US$6.2 billion and accounting for 76% of total donor government funding in 2020. The second largest donor was the U.K. (US$612 million, 7%), followed by Japan (US$258 million, 3%), Germany (US$246 million, 3%), and France (US$216 million, 3%). Over the past decade, the U.S. has accounted for an increasing share of total donor government funding, rising significantly since 2010 when it accounted for 54% of total disbursements. The increasing share by the U.S. is largely attributable to declines in bilateral funding from other donors (see below).

While most funding from donors is provided bilaterally (69%), largely driven by the U.S. (which provides 82% of its funding through bilateral channels), the majority of donors (ten – Australia, Canada, European Commission, France, Germany, Italy, Japan, Norway, Sweden, and the U.K.) 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$5.6 billion in 2020, a decline of almost US$100 million compared to 2019 and marking the third year in a row of declines. All donor governments decreased bilateral funding in 2020, with the exception of the U.S., which was flat (See Figure 3). These trends were the same after accounting for inflation and exchange rate fluctuations.

Declines in bilateral funding from donor governments, other than the U.S., are part of a decade long trend. Since 2010, while bilateral funding from the U.S. has been mostly flat, funding from all other donor governments has decreased by more than US$1 billion dollars and these declines have not been offset by increased multilateral support from some donors (See Figure 4 and Figure 5). As a result, the U.S. has taken on an increasing share of donor government bilateral disbursements accounting for 67% in 2010 and rising to 91% in 2020.

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 $2.6 billion in 2020 (after adjusting for an HIV share to account for the fact that the Global Fund and UNITAID address other diseases).3 Funding was US$2.3 billion for the Global Fund, US$67 million for UNITAID, and US$191 million for UNAIDS.

While donor government contributions to multilateral organizations reached the highest level to date in 2020, rising by almost US$500 million compared to the 2019 level (US$2.1 billion), the increase was due to a small set of donors. In fact, only 4 of 14 donors (Germany, Japan, the U.K., and the U.S.) increased their multilateral contributions (largely due to their increased contributions to the Global Fund), while eight (Australia, Canada, Denmark, France, the Netherlands, Norway, Sweden, and the European Commission) decreased, and two remained flat (Ireland and Italy). These trends were the same after adjusting for inflation and exchange rate fluctuations.

In 2020, the U.S. contribution to the Global Fund (calculated as an HIV-adjusted share of the total contribution) nearly doubled from US$552 million in 2019 to almost US$1.1 billion. This increase, however, was almost entirely due to the disbursement in 2020 of funds appropriated by Congress for the Global Fund in prior years, and is not expected to continue at this level in 2021. In addition to the U.S., three other donors (Japan, Germany, and the U.K.) increased their contributions to the Global Fund.

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 2020, followed by the U.K., Japan, 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 2020 ($21.7 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 their 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), putting the U.S. on top, followed by the U.K., the Netherlands, and Sweden (Figure 7).

Looking Forward

Funding from donor governments for HIV increased by US$377 million in 2020. This increase is largely attributable to a near doubling of the U.S. contribution to the Global Fund, a function of timing not new political commitments. In addition, donor governments other than the U.S. continued a longer trend of reducing their bilateral funding for HIV, declines not offset by increased contributions to multilateral institutions, including the Global Fund, from some donor governments.

Looking ahead, future funding for HIV from donor governments is uncertain. The funding amounts presented in this report were primarily the result of decisions made prior to the COVID-19 pandemic and may not reflect changes in donor government development funding levels that occurred during the pandemic. While many donor governments are starting to rebound from the global economic recession brought on by COVID-19, recovery still remains below pre-pandemic projections, and the environment is fluid. In addition, the future impact of COVID-19 in low- and middle-income countries remains tenuous, with some experiencing a “third-wave” and most not expected to gain access to vaccines in any significant way for months if not years. This could lead to even greater funding needs for HIV and other health programs. At the same time, several donor governments have provided emergency COVID-19 support to low- and middle-income countries, some of which may help to address lost ground in the HIV response; this includes, for example, emergency funding provided by the U.S. in 2021 to both PEPFAR and the Global Fund. These factors make it difficult to predict what the ultimate impact will be on funding for HIV in the future.

Key Findings Methodology

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