Donor Government Funding for HIV in Low- and Middle-Income Countries in 2022
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 2022. It is part of a collaborative tracking effort between UNAIDS and 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 31 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 31 DAC members, 14 provide 99% of total disbursements and individual-level data are provided for each. For the remaining 17 DAC members, data are provided in aggregate. Both bilateral and multilateral assistance are included (see methodology for more detail).
Findings
Total Funding
In 2022, donor government funding for HIV through bilateral and multilateral channels totaled US$8.2 billion in current USD, an increase of more than US$700 million compared to 2021 (US$7.5 billion) (See Figure 1 and Table 1).1 However, this increase was largely due to the timing of disbursements, particularly for the U.S. (see below), and was not an actual increase in commitments. Total funding in 2022 was essentially a return to prior year levels following a significant decline in 2021, which was similarly due to the timing of disbursements.2
In 2022, donor governments accounted for approximately 37% of the US$22.4 billion estimated by UNAIDS to be available to address HIV (the total is US$20.8 billion when measured in 2019 constant USD); 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$29.3 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$6.1 billion and accounting for 74% of total donor government funding in 2022.7 The second largest donor was France (US$382 million, 5%), followed by the U.K. (US$376 million, 5%), the European Commission (US$328 million, 4%), and Germany (US$191 million, 2%). In 2022, 90% of total donor government funding for HIV was provided by these five donors.
While most funding from donors is provided bilaterally (68%), largely driven by the U.S. (which provided 87% of its funding through bilateral channels), the majority of donors (eleven – Australia, Canada, European Commission, France, Germany, Ireland, 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 donor governments, other than the U.S., direct their funding, falling from 54% provided through bilateral channels in 2011 to only 16% in 2022 (see below).
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$5.6 billion in 2022, an increase of almost US$130 million compared to 2021 (US$5.5 billion). This increase, however, was almost entirely due to the U.S. as bilateral funding from most donor governments either decreased or remained essentially flat in 2022; Denmark and France were the only other donor governments that increased bilateral support (See Figure 3). These trends were the same after accounting for inflation and exchange rate fluctuations except for the U.K., which was flat when measured in currency of origin.
While U.S. bilateral disbursements increased by more than US$200 million in 2022 (US$5.3 billion) compared to 2021 (US$5.1 billion) (See Figure 4), the change was due to the timing of disbursements of prior year funding and was not an actual increase in commitments. In fact, bilateral HIV funding as specified by the U.S. Congress in annual appropriations has been flat for several years.8
When the U.S. increase is removed, bilateral funding from all other donor governments decreased by almost US$90 million in 2022 continuing a more than decade-long trend of declining bilateral support. Since 2011, funding from donor governments, other than the U.S., has decreased by almost US$1.4 billion (80%), declines which have not been fully offset by increases in multilateral contributions (See Figure 5 and “Multilateral Contributions” below). As a result, the U.S., which has historically provided the majority of bilateral resources from donor governments, has accounted for an increasing share, rising from 70% in 2011 to 94% in 2022.
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 US$2.6 billion in 2022 (after adjusting for an HIV share to account for the fact that the Global Fund and UNITAID address other diseases).9 Funding was US$2.4 billion for the Global Fund, US$58 million for UNITAID, and US$160 million for UNAIDS.
Donor government contributions to multilateral organizations increased by almost US$600 million in 2022 (US$2.6 billion) compared to the 2021 level (US$2.0 billion), largely due to the timing of contributions to the Global Fund by the U.S., France, and the European Commission. Timing of U.S. contributions to the Global Fund are based in large part on the amount of funding received from other donors, as the U.S. is required by law not to exceed 33% of total contributions to the Global Fund from all donors. For many of the other donor governments, Global Fund contributions tend to fluctuate over the Global Fund’s three-year pledge periods, with some donors providing significant contributions at the beginning of the period, resulting in declines in subsequent years, while others choose to fulfill pledges towards the end of the pledge period, resulting in what appears to be significant increases. For example, in 2022, the European Commission provided a large portion of its pledge for the Global Fund’s 2023-2025 replenishment period. Conversely, the increase in 2022 by France was towards fulfillment of its pledge for the 2020-2022 replenishment period as it provided smaller contributions in the preceding years.
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 France, the U.K., European Commission, 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 2022 (US$22.4 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, France, and Sweden. (Figure 7).
Looking Forward
As this report finds, the donor government funding pie, which accounts for more than a third of all global HIV resources annually to low- and middle-income countries, has not been growing; rather, funding has fluctuated for several years, with year-to-year changes largely due to the normal ebb and flow of payment timing and Global Fund pledging periods. In fact, current levels are below the high-water mark of almost a decade ago due to decreasing bilateral support from donor governments other than the U.S. As a result of these trends, five donor governments (U.S., France, U.K., Germany, and European Commission) now account for 90% of total donor government funding. Moreover, while there has been significant progress in addressing the HIV epidemic —there were 1.3 million new infections in 2022, down from approximately 2 million a decade ago, and almost half as many AIDS-related deaths—new infections and AIDS-related deaths are on the rise in some regions, including in Eastern Europe and Central Asia and the Middle East and North Africa. Further, more than 9 million people living with HIV still lack access to antiretroviral therapy.10
Looking ahead, if these trends continue, the financing outlook for 2023 and beyond will likely be dependent on fulfillment of pledges to the Global Fund for the 2023-2025 replenishment period, which was the highest ever and included significant increases from many donors. Notably, for the first time in many years, the U.S. increased its Global Fund pledged commitment to US$6 billion over 3 years (US$2 billion/year), or a more than US$400 million increase per year.11 This resulted in a US$2 billion appropriation by the U.S. Congress for the Global Fund in 2023. However, the extent to which this full amount can be provided will depend on funding from other donors, as the U.S. is required by law not to exceed 33% of total contributions to the Global Fund from all sources. As such, future U.S. funding commitments to the Global Fund could be reduced. These trends and questions moving forward, combined with continued stresses on domestic government budgets, create an uncertain future.