Donor Government Funding for HIV in Low- and Middle-Income Countries in 2021

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 2021. It is part of a collaborative tracking effort between UNAIDS and the 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 30 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 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 2021, donor government funding for HIV through bilateral and multilateral channels totaled US$7.5 billion in current USD, largely flat compared to the prior year after accounting for the timing of contributions to the Global Fund (see below). Looking more broadly, funding in 2021 is approximately at the same level as 2008, in nominal terms, and has fallen over the period due to the effects of inflation (See Figure 1 and Table 1).¹ These trends are occurring as inflation continues to rise and funding for HIV from other sources, particularly domestic resources, is on the decline.²

In 2021, donor governments accounted for approximately 37% of the $22.6 billion estimated by UNAIDS to be available to address HIV; domestic resources accounted for 60%, and the remainder was from foundations, other multilateral organizations, and UN agencies.^3,4,5 This amount is well below the US$29 billion that UNAIDS estimates will be needed by 2025 in order to reach global goals.⁶

The U.S. continued to be the largest donor to HIV efforts, providing US$5.5 billion and accounting for 73% of total donor government funding in 2021.⁷ The second largest donor was the U.K. (US$385 million, 5%), followed by Germany (US$246 million, 3%), the European Commission (US$232 million, 3%), and France (US$230 million, 3%).

While most funding from donors is provided bilaterally (73%), largely driven by the U.S. (which provides 92% 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). Over the past decade there has been a significant shift in how all donor governments, except for the U.S., direct their funding. In 2011, the majority of funding from these donors (excluding the U.S.) was provided bilaterally (54%), whereas by 2021 the bilateral share from these donors had declined to 21%.

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$5.5 billion in 2021, a decline of more than US$100 million compared to 2020 and marking the fourth year in a row of declines. Bilateral funding from most donor governments either decreased or remained flat in 2021; most of the decline in 2021 was from the U.K., the second largest bilateral donor. Australia, Germany, and Sweden were the only donors to increase funding (See Figure 3). These trends were the same after accounting for inflation and exchange rate fluctuations.

Combined bilateral funding from donor governments, other than the U.S., decreased again in 2021 continuing a more than decade-long trend of declining bilateral support. Since 2011, while bilateral funding from the U.S. has been mostly flat, funding from all other donor governments has decreased by almost US$1.3 billion dollars, declines which have not been fully offset by increased multilateral support from some donors (See Figure 4 and Figure 5). As a result, the U.S., which has also provided the majority of bilateral resources, has accounted for an increasing share, rising from 70% in 2011 to 92% in 2021.

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 $2.0 billion in 2021 (after adjusting for an HIV share to account for the fact that the Global Fund and UNITAID address other diseases). Funding was US$1.8 billion for the Global Fund, US$44 million for UNITAID, and US$165 million for UNAIDS.

Donor government contributions to multilateral organizations decreased by US$561 million in 2021 (US$2.0 billion) compared to the 2020 level (US$2.6 billion). However, the decline was due to the timing of disbursements by several donors to the Global Fund, but not to a decrease in actual support. Rather, Global Fund contributions tend to fluctuate over the organization’s three-year pledge periods, with some donors providing significant contributions at the beginning of the period, resulting in declines in subsequent years (e.g. U.K. and Japan), while others choose to fulfill pledges towards the end of the pledge period, resulting in what appears to be significant increases (e.g. Canada and the European Commission) and others fluctuate from year-to-year simply due to the timing of disbursements (U.S.).⁸

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 the U.K., Germany, European Commission, and France. 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 2021 ($22.6 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, Sweden, and the U.K. (Figure 7).

Looking Forward

The past year marked the second in a row that the world has been confronted with the COVID-19 pandemic, which has had direct and indirect effects on other health issues including HIV, and has negatively affected the global economy.^9,10,11,12 While COVID-19 does not seem to have impacted donor government support for HIV in 2021, after accounting for the timing of payments to the Global Fund, it has not kept pace with inflation and several donors have reduced their support for HIV over the past decade. This comes at a time when there is an approximate US$8 billion funding gap to reach 2025 targets compared to the total HIV resources in L&MICs, and also at a time when introduction of new technologies, such as long acting injectables, could make a difference to bending the trajectory of the epidemic. As such, the future is uncertain. COVID-19 is ongoing and continues to put pressures on the global economy. In addition, some donor governments have directed significant resources towards Ukraine and some have announced that their ODA budgets will be impacted as a result of costs associated with supporting an influx of refugees. Combined with other global challenges, such as rising inflation, this creates an uncertain path for donor budgets. One of the biggest markers ahead for future HIV funding will be the Global Fund’s 7^th replenishment this fall, the outcome of which will likely set the stage for donor support for years to come.