The Global Response to HIV and AIDS: Context and Funding

1. The Global Response to HIV and AIDS:Context and Funding Hope for Life International Gathering 29 October, 2019 eMseni Christian Center Johannesburg, South Africa Dr. Robert Carter

2. Since the AIDS Epidemic Began… • 75.9 million people have been infected with the HIV virus, and • 32 million people have died from HIV-related causes.

3. Summary of the global HIV epidemic (2018) = 4660/day 0.8million 37.9million 1.7million 2018 HIV-related deaths people newly infected people living with HIV [0.6 million –1.1 million] [1.4 million – 2.3 million] [32.7 million – 44.0 million] + 2550 / day Source: UNAIDS/WHO estimates = 2110/day

4. Summary of the global HIV epidemic (2018) HIV-related deaths 2018 People living with HIV in 2018 People newly infected with HIV in 2018 37.9 million [32.7 million – 44.0 million] 1.7 million [1.4 million – 2.3million] 770 000 [570 000 – 1.1 million] 1.6 million [1.2 million – 2.1 million] 670 000 [500 000 – 920 000] 36.2 million [31.3 million – 42.0 million] 18.8 million [16.4 million – 21.7 million] – – 17.4 million [14.8 million – 20.5 million] – – 100 000 [64 000 – 160 000] 160 000 [110 000 – 260 000] 1.7 million [1.3 million – 2.2 million] Source: UNAIDS/WHO estimates

5. UNAIDS - 2017New Infections: Where? And to Whom? • In 2017 there were about 5000 new HIV infections/day (adults + children). • About 66% were in sub-Saharan Africa. • About 500 (10%) were among children less than 15 years of age. • The other 90% were among adults 15 years and older, of whom: • About 33% were among young people (15-24 years). • About 19% were among young women (15-24 years).

6. Vulnerability of Women Women are more vulnerable to HIV than men, and younger women are more vulnerable than older women. (But everyone is vulnerable…) In Africa: • 58% of adults living with HIV are women. • Infection rates in young African women are far higher than in men of the same age – in some countries and age groups, by four times. This is due to the virus being passed from older men to younger women. • In Sub-Saharan Africa, 3 out of every 4 new HIV infections in teens 15-19 years old occurs in girls.

7. Why are women more vulnerable to acquire HIV than men? Biological Factors - • Reproductive anatomy has greater surface area, inner skin of the vagina is more tender, traumatizes more easily. • Women tend to be more poorly nourished than men. • The virus is six times more easily transmitted from a man to a woman than from a woman to a man. Socio-cultural Factors - • Certain practices (i.e., “dry sex”) increase risk of sexual trauma. • Power differentials: women cannot say “no” to men who have authority over them. • Women’s lack of control over their sexual lives (i.e., cannot insist on condom use.) • Women are subject to cultural practices that increase risk: sexual cleansing, wife inheritance, wife sharing, child marriages, etc.

8. Why are women more vulnerable to acquire HIV than men? Financial Factors - • Dependence on male providers (“sugar daddies” and “sponsors”). • Less access to means of earning income (sex work / seasonal sex work / child prostitution). • Less access to education = less access to good jobs. • Lower pay than men for the same work. • Inheritance goes to sons, not daughters. • Poverty leads to poor health, poor nutrition, greater vulnerability, greater likelihood of resorting to high-risk means of generating income.

9. Why are women more vulnerable to acquire HIV than men? Religious Factors - • Women are subordinate to men. A wife is the domestic servant of her husband, with little or no decision-making power. • Wives must obey their husbands and give them sex no matter what, even if he is unfaithful, drunk, abusive, a known womanizer, etc. • Cannot insist on condoms because “condoms are sin”. • A wife’s duty is to produce as many children as is biologically possible, which worsens health and financial vulnerabilities.

10. Gender-Based Violence Gender-based violence (GBV) has been shown to be a factor in spreading HIV. Some examples from Kenya: • In a 2003 survey: • Almost half of adult women reported having been at some time the victim of gender-related violence. • About ¼ of non-virginal females ages 12-24 years reported having lost their virginity by forced intercourse. • In the 2014 Kenya Demographic and Health Survey (KDHS): • Over half ever-married adult women reported experiencing physical (38%) or sexual (14%) violence from their male intimate partner within the past 12 months.

11. PLWH Africa = 25.7 million = 68% global total Global Total = 37.9 million

12. Incidence Africa = 1.1 million = 65% global total Global Total = 1.7 million

13. Mortality Africa = 470,000= 61% global total Global Total = 770,000

14. UNICEF - Children HIV Statistics 2018(0-14 years) 90% 1.73 Million 1.55 Million 87.5% 160,000 140,000 88% 100,000 88,000

15. Childhood HIV Incidence

16. Global HIV epidemic – people living with HIV Trend over Time 2018 Globally 37.9 million People living with HIV +20% Relative to 2010 +41% Relative to 2000 Source: UNAIDS/WHO estimates

17. Global HIV epidemic – incidence and mortality since 2010 and 2000 - 16%* New infections relative to 2010 2018 Globally 1.7 million New HIV Infections - 37% New infections relative to 2000 - 33% Fewer deaths relative to 2010 2018 Globally 770,000 HIV-related Deaths - 45% Fewer deaths relative to 2000 Source: UNAIDS/WHO estimates *41% drop in incidence in children since 2010 – why?

18. Decline in HIV incidence and mortality over time Peak incidence 1996 -47% from peak Peak mortality 2005 -60% from peak Source: UNAIDS/WHO estimates

19. Global Trends in HIV and AIDS: People Living with HIV

20. HIV in “Key Populations” A “key population” is a people group characterized by traits that tend to be associated with high-risk behaviors and among whom HIV transmission rates are significantly higher than in the general population. These people groups are “key” because the global HIV epidemic will never be brought to an end unless resources and services are focused on controlling HIV in these populations. They include: • Sex workers (SWs) • Men who have Sex with Men (MSM) • Injection Drug Users (IDUs) • Transgender people (Trans)

21. Distribution of new HIV infections by key population, global (2018) Sex workers 6% People who inject drugs 12% Gay men and other men who have sex with men 17% Remaining population 46% Transgender women 1% Clients of sex workers and sex partners of other key populations 18% Source: UNAIDS specialanalysis, 2019

22. Eastern and Southern Africa Region Distribution of New HIV Infections (2017) (Who is getting infected?) • Sex workers - 2% • IDUs (Injection Drug Users) - 1% • MSM (men who have sex with men) - 6% • Sexual partners of “key populations” - 8% • All others - 83% (primarily through unsafe heterosexual intercourse, both singles and marrieds)

23. HIV in “Key Populations” The following 2018 global statistics are notable: • In 2018, 54% of global new infections occurred in key populations and their sexual partners. • Risk of acquiring HIV was 22 times higher among gay men or other MSM than compared to heterosexual men. • Risk of acquiring HIV was 22 times higher among IDUs than compared to people who do not inject drugs. • Risk of acquiring HIV was 21 times higher among female sex workers than among other adult women. • Risk of acquiring HIV was 12 times higher among transgender women than among other adult women.

24. Global Targets 2020 / 2030 - Incidence

25. Global Targets 2020 / 2030 - Mortality

26. UNAIDS: 90-90-90 Treatment Targetsby 2020 Target 1:90% of HIV+ peoplediagnosed Target 2:90% of diagnosed people on ART Target 3:90% of people on ART are virally suppressed 100 90% 81% 80 73% 60 People (%) 40 20 0 HIV Positive People Diagnosed On ART Viral Suppression Levi J, et al. IAS 2015. Abstract MOAD0102. Reproduced with permission.

27. HIV testing and care continuum, global (2018) Source: UNAIDS/WHO estimates

28. HIV testing and care continuum, global (2018) Cumulative Impact of Falling Short 90% 81% 11% 73% 19% 20% Source: UNAIDS/WHO estimates

29. HIV testing and care continuum by WHO region (2018) % to 90-90-90 PLHIV who know their status (%) PLHIV receiving ART (%) People virally suppressed among all PLHIV (%) Source: UNAIDS/WHO estimates

30. (By 2030, the Target is 95-95-95.)

31. Increase in people receiving ART over time Source: UNAIDS/WHO estimates

32. Increase in people receiving ART over time PLWH accessing ART has almost tripled from 7.5 million in 2010 to 21.7 million in 2017. In these 7 years: • Access has increased from 23% to 62% in adults. • Access has increased from 21% to 43% in children. • 80% of all pregnant women globally living with HIV have access to ART to prevent vertical transmission. • Africa is slightly behind at 75%.

33. Sources: • https://www.who.int/gho/hiv/en/ Accessed 24/8/19 • https://ourworldindata.org/hiv-aids Accessed 24/8/19 • https://www.avert.org/global-hiv-and-aids-statistics Accessed 24/8/19 • https://www.unaids.org/en/resources/documents/2018/unaids-data-2018 Accessed 24/8/19 • https://www.unaids.org/sites/default/files/media_asset/UNAIDS_FactSheet_en.pdf accessed 24/8/19 • https://www.kff.org/global-health-policy/fact-sheet/the-global-hivaids-epidemic/ accessed 24/8/19

34. Global Funding - History • In 2011, the United Nations’ Political Declaration on HIV and AIDS called on the international community to mobilize US$22-24 billion for the global HIV response in low- and middle-income countries by 2015.  • This funding target was missed. By the end of 2016 (a year beyond the target), only US$19.1 billion had been made available. • Of this amount, domestic (in-country, national government) spending exceeded funds provided by external donors and accounted for the majority of global HIV funding (57%). • Low- and middle-income countries must increasingly finance their own HIV responses. Yet many low- and middle- income countries continue to remain heavily dependent upon international donors to finance their HIV response. In 2014, 44 countries had 75% or more of their HIV financing needs provided by external sources.

35. Global Funding - History • To be on course to end AIDS as a public health threat by 2030, UNAIDS estimates that US$ 26.2 billion will be required for the global HIV response in 2020 alone. • This means the world must increase the amount of resources available for HIV by US$ 1.5 billion each year between 2016 and 2020, a situation that is looking increasingly unlikely. • Also in 2011, the UNAIDS Strategic Investment Framework encouraged countries to prioritize their spending on population groups most affected by HIV (“key populations”) in order for funding to have the highest, most efficient impact.   • However, a lack of investment in key population programs remains a persistent issue.

36. Global Funding - Trends • International funding for the global HIV response has remained flat over the past few years after peaking in 2013. • In recent years, high-income countries have reduced funding for the HIV response in low- and middle-income countries, with a 7% decrease reported between 2015 and 2016. • This continuing trend of disinvestment towards the global HIV response follows several years of flat-line funding since international aid budgets began to be constrained as a result of the economic crisis that hit the developed world in 2008.

37. Global Funding - Trends • Donor government disbursements to combat HIV in low- and middle-income countries totaled US$8 billion in 2018, little changed from the US$8.1 billion total in 2017 and from the levels of a decade ago. • Since 2010, donor governments other than the United States significantly reduced their funding for HIV, which fell by more than $1 billion in the aftermath of the global financial crisis, and with the competing aid demands of a global refugee crisis and other humanitarian challenges. • Most of the decline was in bilateral (direct government-to-government) support. 

38. Global Funding - Trends Funding declines were seen in all sectors in 2018: • Domestic resources (a 2% decline), • The Global Fund (a 20% decline, explained by fluctuations in its three-year grant cycle), • Other multilateral channels (a 2% decline), • The Government of the United States of America’s bilateral programs (a 3% decline), • The bilateral programs of other donor countries (a 17% decline), • Philanthropic organizations (an 18% decline), and • Other international sources (a 4% decline).

39. Global Funding - Trends • There was a decline of $1 billion across all sources of funding between 2017 and 2018, leaving a $7 billion gapbetween resources and need in 2020 after adjusting for inflation. • Some of the “missing” funding from donor governments is simply being redirected to other emerging global health priorities such as cancer and other non-communicable diseases. • Given the inadequate funding being currently experienced from all the major sources, some voices are now calling for identifying and mobilizing other, additional sources of funding. Apart from out-of-the-box thinking, supply may fall short of need indefinitely.

40. 2020 Target $7B

41. Global Funding - Trends • In 2016, the UN General Assembly Political Declaration on Ending AIDS agreed to a steady scale-up of investment in the AIDS responses in low- and middle-income countries, increasing to at least US$ 26 billion by 2020. • Instead of a steady increase, however, global financing for HIV is decreasing. The political commitment is simply not being matched with the financing required to bring to reality the vision of ending the global AIDS pandemic by 2030. • To maximize the impact of the limited resources available, there is a need to significantly reallocate existing resources to services for populations with the highest need and with the highest potential impact.

42. International Funding • International HIV funding from donor governments is provided through both bilateral and multilateral channels. International investment in the HIV responses of these countries peaked in 2013 at nearly US$10 billion; it has since declined to around US$8 billion in 2018. • Since 2006, 80% of all HIV funding from donor governments has come from only 5 countries: the US, UK, France, Netherlands and Germany (in that order). • The USA accounts for the majority of bilateral and multilateral funding from donor governments. Its FY 2019 budget designates $6.8 billion for the global HIV response. • About ¾ of funding from donor governments is given through bilateral (direct government-to-government) channels.

43. Domestic Funding • Low- and middle-income countries are increasingly financing their AIDS responses themselves. • Between 2010 and 2018, domestic resources invested by low- and middle-income countries in their AIDS responses increased by 50%, while international investments increased by just 4%. • In the face of donor stagnation there is increasing emphasis on countries most affected by HIV to finance their own responses and find more efficient and cost-effective ways to do so. • On average, low- and middle-income HIV/AIDS-affected countries funded roughly 56% of HIV/AIDS programs in 2018.

44. Domestic Funding • Although challenging, shifting towards domestic funding has advantages. These include: • Fostering ownership and accountability in the implementation of the national HIV response, and • Increased sustainability of national HIV efforts.

45. Private Philanthropic Funding Private philanthropic organizations provided US$680 million for global HIV and AIDS programs in 2016, a 2% increase from 2015, the third consecutive year of growth. • The two largest funders were the Bill and Melinda Gates Foundation and Gilead Sciences, representing over half of all philanthropic funding in 2016. • The top intended use for funding from philanthropic donations was research (37%) followed by prevention (25%).

46. The Global Fundto fight AIDS, TB and Malaria The Global Fund prioritizes: • countries with high disease burden, • countries where the proportion of key populations is highest, and • countries where national health systems lack capacity to respond to HIV. The Global Fund has been instrumental in funding a large majority of key population programs in many countries. For example, it is the world’s largest investor in harm reduction programs for people who inject drugs.

47. The Global Fundto fight AIDS, TB and Malaria In September 2016, the Fifth Replenishment of the Global Fund saw governments and private sector donors commit US$12.9 billion between 2017 and 2019. This was very close to the US$13 billion target. Then at its Sixth Replenishment Conference held in Lyon, France, on 9 and 10 October 2019, the Global Fund raised US$ 14.02 billion for the three years 2020-2022, the highest amount it has ever raised. The U.S. is the Global Fund’s largest contributor. It’s 2019 budget includes $1.35 billion for the Global Fund, which is flat compared to its 2018 level.

48. The President’s Emergency Plan for AIDS Relief (PEPFAR) • PEPFAR is a US government program started in 2003 as a five year, US$15 billion commitment to tackle the global HIV and AIDS epidemic. It has continued to this date and has spent more than US$70 billion in more than 50 countries on programs to combat HIV and AIDS, tuberculosis, malaria and other opportunistic infections.  • As of September 2017, PEPFAR was supporting antiretroviral treatment (ART) for more than 13.3 million people and had funded 85.5 million HIV tests in that year alone, including for more than 11.2 million pregnant women.  PEPFAR narrowed its 2017-2020 strategy to focus especially on 13 highly-affected countries.

49. The President’s Emergency Plan for AIDS Relief (PEPFAR) All U.S. funding for global HIV is considered to be part of PEPFAR, including both bilateral HIV efforts as well as contributions to multilateral organizations, such as the Global Fund. However, since 2010 funding for PEPFAR has remained essentially flat.

50. HIV and AIDS Funding:What Does the Future Look Like? The future outlook of global funding for the HIV response remains uncertain. • In 2018, the United States, the largest contributor to the global response, proposed cuts of US$1 billion. • For its proposed FY 2020 budget, the Trump Administration has requested 29% less for PEPFAR than in the previous year. • Fortunately, PEPFAR continues to receive bipartisan support in Congress, which has appropriated global health and HIV/AIDS funding over the past three years at levels consistent with funding during the preceding Obama administration.