On Saturday, April 2, UNAIDS released revised resource needs estimates that reflect important new analysis about what it will take to put the world on the "fast track" to ending the AIDS crisis by achieving the 90-90-90 treatment goals. UNAIDS calculates $26.2 billion is needed in low- and middle-income countries by 2020 in order for the world to reach a critical tipping point, after which the cost of the response will begin to fall. The 2020 funding gap is roughly $6 billion -- about what Americans will spend on Independence Day celebrations this year or what US Presidential candidates will spend on ads this election cycle. This is an entirely achievable goal.
Unfortunately, UNAIDS seems to be engaging in magical thinking about which countries can and will bridge this funding gap that ignores important political realities. The agency's new projections about what is needed to end the AIDS epidemic make completely unrealistic and unreasonable expectations about what low- and middle-income countries can and will pay -- suggesting a dangerous donor strategy in the face of high stakes. Low- and middle-income countries can and must pay more -- leading AIDS activists from high burden countries have long demanded this and are, in many cases, winning increases. But UNAIDS itself predicts that if the money needed to close this gap does not materialize by 2020, we will not hit the fast track goals. The result will be a nightmare scenario of tens of millions of preventable deaths and new infections and an epidemic raging out of control.
Unrealistic Expectations in Low and Lower-Middle Income Countries
The report acknowledges that domestic investment "nearly tripled" in 8 years, between 2006 and 2014. Yet, somehow in the next five years, UNAIDS imagines that:
- Low Income countries will increase domestic funding for the response from $200 million to $900 million per year -- a 450% increase
- Lower-Middle Income countries will increase domestic funding for the response from $700 million to $3.7 billion per year -- a 530% increase.
In the coming years countries will have to lead the way by radically and rapidly shift their models of care and HIV services at unprecedented rates -- and increasing domestic financing. However, the rate of scale up imagined in the UN projections ignore the real-world political and economic realities facing many people living with HIV and their governments in high burden countries: from the falling price of copper that is crippling the Zambian economy, to orders by the International Monetary Fund to cut public sector workers in Malawi, and right-leaning governments in India and Thailand hostile to expanding budgets for marginalized people.
"Sub-Saharan Africa faces a challenging near-term outlook," declared the World Bank in January. And more broadly: "In the current environment, developing countries need to brace for possible shocks by building resilience to risks to growth."
Does UNAIDS believe 450% and 530% increases will uniformly materialize in the next few years to respond to a disease that is still stigmatized and disproportionately born by marginalized communities? If UNAIDS does not expect these levels of funding increases, then isn't it irresponsible to suggest donors should base funding decisions on these assumptions?
Radical Pull Out From Upper Middle-Income Countries With Large Generalized and Concentrated Epidemics
Of the 35 countries that UNAIDS identifies as accounting for 90% of HIV infections worldwide, 10 are upper-middle income countries, including South Africa, Namibia, Botswana, Thailand, and Indonesia. However, in the next 5 years, UNAIDS imagines that:
- Donor contributions to upper middle-income countries should fall to one-third of current levels by 2020 -- to just $500 million per year.
At present, South Africa, Namibia, and Botswana alone receive over $500 per year million from just PEPFAR and the Global Fund. The implications are thus unclear: Does UNAIDS propose to cut these highest burden countries back to $500 million? Should the rest of the upper middle-income countries then receive $0 in HIV assistance from all donors? While many of these countries are now showing clear political will, they will continue to need significant help to reach millions of currently un- or under-served patients. Such deep cuts as the end of the AIDS crisis is in sight but not yet reached could be disastrous. We have been critical of the Global Fund for pulling back too much support in UMICs -- but even Global Fund policy would not go anywhere near this far.
No Attention to Human Rights Concerns and Political Realities
In most financing analyses of HIV, considerations of human rights and global solidarity are central. Many country governments in both the global North and South have demonstrated neglect and hostility to the needs of key affected populations -- men who have sex with men, transgender people, sex workers, people who use drugs, and others. This politics of AIDS is reflected in the funding of AIDS. The story of HIV, which UNAIDS tells well in its 2015 report "How AIDS Changed Everything," is a story of international solidarity helping to transform the response to an epidemic, with external financing proving essential for programs for key affected populations. Continued scale-up of key populations programming is critical to the success of the UNAIDS fast track approach.
Yet the new UNAIDS attribution of funding makes no acknowledgement that funding decisions in this light are manifestly political -- that donor funding is sometimes necessary to leverage increased drive for evidence based programming in implementing countries. It further makes no calculations about how the billions in funding for key populations, community mobilization, and social enablers accords with its ideas of who should pay: Would massive pull-back from upper middle-income countries, for example, decimate key populations programming? And, what portion of the autocratic regimes included in the analysis does UNAIDS expect will sufficiently fund the community mobilization critical to the success of the fast track strategy?
Where's the Fiscal Space Analysis for Donors?
Perhaps the most striking feature of the new resource needs estimate, is one seemingly essential element that is completely absent: UNAIDS conducts no "fiscal space" analysis for donor governments. While suggesting 450% and 530% increases for LICs and LMICs, donors are asked to increase their funding by merely 31%. This is despite evidence that much of the global economic growth since the 2008 financial crisis has gone to top earners in wealthy countries.
There is no evidence this is what donors "can" pay and ample evidence that significantly more than this will likely be needed in donor contributions. The Fast-Track approach "requires front-loading investment: a rapid increase in resources allocated to HIV during the next few years to achieve greater long-term gains and reduce the resources needed in the future." Missing this window would have devastating results.
Ending the AIDS pandemic in our lifetimes requires politically-informed, human rights-based strategies to mobilize sufficient resources. The world needs $26 billion by 2020 in order to front-load the investment needed to end the AIDS crisis. Who pays what matters far less to people living with HIV than the fundamentally political question of whether all governments can be made to come together to fill the $6 billion gap.
UNAIDS has a critical role in mobilizing global political solidarity for success -- which is why it is baffling that they have missed this point by suggesting that donors ought to act on unrealistic expectations.
Matthew Kavanagh is senior policy analyst for Health Global Access Project, a fellow at the University of Pennsylvania's Leonard Davis Institute for Health Economics, and an AIDS activist since he can remember.