What’s holding back the fight against HIV?

A nurse and trainee at work in CHK hospital in Kinshasa, Democratic Republic of Congo, run by Médecins Sans Frontières (MSF), June 2017. (Credit: MSF/Kris Pannecoucke)

As HIV and Aids continue to impact millions of people around the world, humanitarian organisations warn that donations to fight the disease are flatlining, threatening decades of gains and pushing the global response further off track.

In a damning report released last summer, the United Nations warned that the world is “losing the fight” against HIV after years of steady progress. UNAids found that 1.5 million new infections had been reported in the previous 12 months, as countries continued to grapple with the ongoing Covid-19 pandemic and its impact on global health. The new estimates exceeded global targets by three times and pushed the fight against the disease dangerously off track.

The agency warned that “faltering progress” had been driven by donors redirecting resources to fight Covid-19 and other crises, and by low and middle-income countries cutting domestic funding for two consecutive years. In 2021, there was an $8 billion gap in lower income countries. Cases jumped for the first time in a decade in Asia and the Pacific, while central Asia, Latin America, the Middle East and North Africa all saw increases in cases.

Despite effective HIV treatment and tools to prevent HIV infections, 650,000 people died from Aids in 2021, according to UNAids, equivalent to one fatality per minute. The funding shortfall and disrupted access to testing and treatment put millions of lives at risk and threatened to derail decades of gains made around the world, it said.

“When international support has been most needed, global solidarity has stalled,” warned UNAids executive director Winnie Byanyima. “Leaders must not mistake the huge red warning light for a stop sign. This must become a moment for a surge of international support.”

Six months on from the report, countries and organisations are still working to get the global HIV/Aids response back on track. Some expressed relief in November when The Global Fund to fight Aids, Tuberculosis and Malaria announced it had raised a record $15.7 billion of financial support in its latest replenishment drive, which was held in September but reached its final total in November after a number of donors including Italy and the UK made late pledges.

Read also: Discrimination and inequality holding back fight against Aids, UN warns

The fund’s board approved in-country allocations of $13.2bn to 120 nations to support them in their fight against the three diseases, while $518 million will go towards what it described as catalytic investments.

The amount exceeded what was raised in the previous cycle, with many countries increasing their commitments and new donors stepping forward for the first time, such as Indonesia and Malawi. Siobhan Crowley, head of HIV at The Global Fund, said the organisation was “relieved” by the amount raised against the backdrop of a tough global economic environment and when many countries are facing a myriad of crises.

“I think it was reassuring to see the commitment,” she told Geneva Solutions. “It was brilliant. And we saw people contributing this time who haven’t contributed before, and people investing at higher levels.”

However, the total still fell far short of the $18bn the Geneva-based organisation asked for, which it described as the “minimum to get the world back on track” towards ending the three diseases as well as building more resilient health systems and strengthening pandemic preparedness. Any less, it said, could further stall the fight against Aids, TB and malaria and cost millions of lives.

The Global Fund’s Crowley said that while it was “disappointing” not to have met their target, the funding meant that country allocations would be “somewhere in the ballpark” of the previous three years. However, she acknowledged that this would leave countries with difficult decisions on where to direct funds in the face of increasing demands.

“Obviously the tension for us is that we have a strategy that is far more ambitious, so there will be some sort of trade-offs that we will have to look at,” she said. “It's certainly not enough to realise all the ambition, so I have to say that is a shame. But there's never enough money.”

Funding shortfall leaves gaps

Organisations working on the ground to combat the diseases warn that funding needs to significantly increase rather than flatline to help nations recover from the fallout of the pandemic.

“At the global level, we see a kind of flatlining or decreasing of external funding,” said Stéphanie Dreze, HIV/TB advocacy coordinator for Médecins Sans Frontièrs (MSF).

“HIV is a chronic disease, so the more years are passing the more people we have on treatment and the more we need to keep on treatment. Then you also need to test people, find positive cases, put them on treatment and make sure they stay in care – it all costs money. So we need to have an increase in funding and we don’t really have that, which is worrying.”

Under the Global Fund’s model, countries receive an allocation of funds for a three-year period. This means it is their decision where the resources will be directed.

Dreze said the shortfall meant that most of the countries she was familiar with would either receive a similar allocation to the previous year or a little less. “It’s not enough to accelerate the response,” she said.

Organisations such as MSF have witnessed the impact of funding restrictions firsthand in recent years. Dreze gives the example of the Democratic Republic of Congo, where MSF has been operating for two decades.

Since MSF opened the first outpatient treatment centre offering free care to people living with HIV in the capital Kinshasa in 2002, huge progress has been made. Access to treatment and care has been massively expanded and hundreds of thousands of nurses have been trained. Over the past 10 years the number of new infections in the country have dropped by half.

However, this work has been constantly carried out against a backdrop of insufficient national and international resources to win the fight against HIV/Aids given the scale of the challenges. The DRC depends almost exclusively on international donors for its HIV/Aids response, and MSF said shortfalls in funding have meant that the government has had to “prioritise among priorities,” leaving dangerous gaps in its response.

There is still a lack of free voluntary testing, a lack of training for healthcare providers, chronic shortages of medicines and massive disparities in HIV services between provinces, according to MSF. Only three provinces have adequate equipment to measure patients’ viral load, which is essential for assessing the evolution of the infection and the effectiveness of treatment, Dreze explained.

In 2021, UNAids still estimated that one-fifth of the 540,000 people living with HIV in the DRC did not have access to treatment and that 14,000 people had died of HIV in the country.

She gives the example of mother-to-child transmission, citing a decline in testing for pregnant women in the DRC which has led to fewer mothers being put on treatment and a heightened risk of their children contracting HIV. A quarter of children born to HIV-positive mothers did not have access to paediatric prophylaxis at birth, to prevent infection, partly due to paediatric antiretroviral (ARV) shortages, according to MSF.

Dreze said that funding shortfalls from the previous grant meant the DRC could only provide testing for pregnant women in 15 out of 26 provinces, leaving a large proportion of pregnant women untested and raising the rate of mother-to-child transmission. Like many countries, there is also a significant treatment gap for children in the DRC, with two-thirds living with HIV not on treatment.

“Funding in general is an issue, and countries have to choose between equally important priorities,” said Dreze. “We know that there are gaps in the response in countries such as the DRC, and [the latest funding shortfall] probably means we will not be able to catch up after the impact of Covid, so we need to accelerate the response.”

She said that while community initiatives in the DRC were successful at keeping people on treatment during the height of the pandemic, there was a significant slow down in testing, which threatens to undo hard-won gains.

“This means we didn’t find people that might develop symptoms because they were not tested last year or the year before, so there is a risk of an increase in mortality rate,” she said.

“In some countries we saw the mortality rate decreasing in the past few years with the help of donors and other actors, but with Covid, it went up or is flatlining in many places instead of going down as we would like to see.”

Although any increase in funds from donors is welcome, organisations are keen to stress that a significant jump is needed to get the global HIV/Aids response on track. In December, UNAids repeated its warning that new infections continued to rise in many parts of the world, while the rate of decline in infections and Aids-related deaths in other regions had slowed significantly. It said resources for the response had “stagnated at levels that are wholly inadequate”.

“There is a common challenge for everyone to make sure that we put all the effort in to make sure that the indicators are going in the right direction, so the mortality rate goes down, the incidence rates go down, and the coverage goes up,” said Dreze.

However, she acknowledged that the focus of some donors may have shifted elsewhere: “It might be a bit difficult in the years to come, because I think there is also some HIV fatigue from donors. It’s not an issue anymore in the Global North, so people are a bit tired of talking about it.”