Fulfilling the promise to ‘make AIDS history’: why the UK

Government should continue to support the HIV response in

middle-income countries – Summary

Full policy brief available at www.aidsalliance.org

Fifteen years ago, two thirds of all people living with HIV resided in low-income countriesi. Since then

the economic status of many countries most affected by the HIV pandemic has changed. Today 58% of

HIV positive people live in middle-income countries (MICs), and by 2020 that is expected to rise to 70%ii.

Of the five countries with the highest HIV burdens globally, three (South Africa, Nigeria and India) are

middle-incomeiii. Some MICs have far lower rates of antiretroviral (ARV) coverage for people living with

HIV than low-income countries, and much higher rates of multi-drug resistant tuberculosis. In Nigeria, a

middle-income country, 32% of people living with HIV and eligible for ARVs are receiving treatmentiv. In

neighbouring Niger and Benin, low-income countries, 46% and 67% respectively of people living with

HIV and eligible for ARVs are receiving treatmentv.

Over the last few years the Department for International Development (DfID) has sought to focus its work

on low-income countries and fragile states. Following its bilateral aid review in 2011, DfID decided to end

bilateral aid programmes in 16 countries, most of them MICs.vi. After this the UK announced further plans

to terminate bilateral aid to South Africa and Indiavii. Sadly, DfID’s bilateral HIV programming has not

escaped this trend. Despite the contextual shift of the HIV pandemic, DfID is cutting nearly all bilateral

HIV funding to MICs. Apart from their programme in Burma, all of DfID’s HIV programmes in Asia have

now closed or are set to close in the near future. DfID argue that they will now support MICs through the

Global Fund to Fight AIDS, TB and Malaria (Global Fund). Yet Global Fund financing for MICs is also

shrinking. The Global Fund is the largest donor for harm reduction programmes, but under the new

funding model less funding will be allocated to harm reduction than was allocated in Round 10. For 2015

and 2016, Ukraine will currently be granted less than half what it was granted for harm reduction for

2013 and 2014. This dramatic cut in funding will have a devastating effect on service provision.

The Global Fund’s new funding model has been influenced by DfID’s and other donor’s rationale that

donor funding to MICs should be reduced or stopped because MICs should be able to fund their own

HIV responses. However, the reality is seldom so straight-forward. Some MICs simply cannot end their

national AIDS epidemic on their own, and need continued donor support in order to sustain and scale up

their HIV responses. For example, the Results for Development Institute estimated that in Zambia, a

new lower-MIC for example, a fully funded HIV response would cost more than 6% of GNIviii. Even an

upper-MIC, such as South Africa, may not, at least in the short term, be able to fully fund its national HIV

response. South Africa is transitioning towards a stronger national health programme and is now

funding 85% of its national HIV response, but the sheer scale of the response needed is a huge

challenge to the country’s resources, ensuring that donor support is still important. In countries such as

Ukraine and Vietnam, governments might be in a financial position to cover their HIV response but are

not yet ready or willing to fund services for key populations. These governments need transitional

political, technical and financial support to move towards an effective HIV response that is targeted to

those groups where HIV prevalence is highest.

For more information on the issues covered in this briefing please contact Mike Podmore, the

International HIV/AIDS Alliance’s Policy Manager at mpodmore@aidsalliance.org or on 07734087950.

i Presentation by Bernhard Schwartländer, Director of Evidence, Innovation and Policy at UNAIDS, to the International AIDS Conference in

Washington, D.C. in July 2012. Available at http://www.cegaa.org/resources/docs/IAC/What_will_it_take_to_turn_the_tide.pdf ii Ibid

iiiGlasman A., Duran D., and Sumner A., Global Health and the New Bottom Billion: What Do Shifts in Global Poverty and the Global Disease

Burden Mean for GAVI and the Global Fund?, Working Paper 270 (2011). Available at http://www.cgdev.org/publication/global-health-and-

new-bottom-billion-what-do-shifts-global-poverty-and-global-disease. iv Antiretroviral therapy coverage among people with HIV infection eligible for ART according to 2010 guidelines (%). Data taken from the World

Health Organisation Global Health Observatory Data Repository (http://apps.who.int/gho/data/node.main.626?lang=en) , 20 May 2014. v Ibid

vi See http://www.publications.parliament.uk/pa/cm201314/cmselect/cmintdev/822/82203.htm

vii Ibid

viii Results for development Institute (2010). Costs and choices: Financing the long term fight against AIDS. Available at

http://r4d.org/knowledge-center/costs-choices-financing-long-term-fight-against-aids.

The International HIV/AIDS Alliance is very concerned that the current emphasis by DfID and a growing number

of other donors on withdrawing financial support for MICs is likely to significantly undermine the global response

to HIV and AIDS. Without a careful and supported transition to domestic funding, the provision of essential

services to key populations, as well as efforts to defend their human rights, will almost certainly be undermined.

The Alliance calls for a new strategic approach by DfID to HIV funding in MICs. We particularly urge DfID to:

Use the UK’s position on the Global Fund Board to champion, not undermine, adequate funding for the HIV response in MICs and to secure a strong commitment by the Global Fund to scale up services for key populations.

Lay out a clear timeframe for the completion of a ‘development finance strategic framework’ that was committed to in the Government’s response to the first phase of the International Development Committee’s inquiry into the future of development cooperation. Ensure that the framework includes allocation criteria and financing instruments that enable the needs of key populations to be met.

In countries where DfID withdraws bilateral aid, work with the FCO to develop a robust transition plan, in coordination with national governments and other key national stakeholders, to sustain services for key populations until a time that country governments are able to fully support the national HIV response themselves.

Develop a theory of change in close consultation with key population networks and communities addressing HIV among young key populations that explains what DfID wants to achieve and how this will be achieved through a combination of approaches and development interventions.

Develop a strategy and funding mechanism to support LGBT equality to defend the human rights of key populations, and counter the rise of state-sponsored homophobia and transphobia.

Work with the FCO to maximise the contribution of the Commonwealth institutions and the Commonwealth Charter to ongoing efforts to repeal discriminatory and punitive laws, including at the 2015 Commonwealth Heads of Government Meeting in Malta.

Continue and scale up investments to strengthen civil society organisations, particularly in MICs and in settings where governments continue to neglect key populations.

Continue to protect access to affordable generic drugs for MICs so that MICs can continue to scale up affordable treatment for HIV and related illnesses.

Maintain global leadership on harm reduction by continuing to invest in harm reduction programmes through the Global Fund and bilateral aid mechanisms, and continue to champion harm reduction as an evidence-driven response with national governments and multinational institutions.