World at risk of losing control of HIV and AIDS epidemic, PEPFAR architect says

25 April 2018

The HIV and AIDS epidemic could become uncontained if current funding trends continue, warned one of the founding architects of the United States President’s Emergency Plan for AIDS Relief.

“We are, in my view, at highest risk ever of losing control of the epidemic since all of this began,” Dr. Mark Dybul said at an event at the Center for Strategic and International Studies in Washington, D.C., on April 18. “Then, what do we do differently? How do we invest differently?”

Dybul’s words about the stark future of the HIV and AIDS epidemic came as the Institute for Health Metrics and Evaluation at the University of Washington released a report about global health financing, which found that development assistance for HIV and AIDS has decreased annually by 5.4 percent since 2012.

The study tracks health spending in 188 countries and logs it by disease, including HIV and AIDS, which has received the largest share of global health spending since 2000, at 26.8 percent. According to the report, the annualized increase of 11.9 percent in funding for HIV and AIDS has “mitigated a major global health crisis.” While money also comes from domestic governments, most low- and middle-income countries rely on development assistance for health to fund their response.

But not enough is being given globally, Dybul said.

“The reality is, and I think what’s behind the numbers, is that no one besides the United States has a bilateral program on HIV anymore,” said Dybul, who helped formulate PEPFAR and then served as its chief medical officer, acting director, and U.S. global AIDS coordinator. He is now the co-director of the Center for Global Health and Quality at Georgetown University.

“There is a larger dependency on basically two organizations, bilateral PEPFAR, and the Global Fund [to Fight AIDS, Tuberculosis and Malaria.] That’s all pretty much all that’s left from external financing perspective. The U.S. leadership in that is huge, and if the U.S. doesn’t maintain its leadership position, the rest of the countries are just looking for an excuse to get out of HIV. They don’t want to be in it,” Dybul said.

In 1995, 18 million people were living with HIV and AIDS and 3 million more were being diagnosed each year, according to the study. The epidemic peaked in 2005, when almost 2 million people were dying from the disease each year and 31 million were living with it. The global campaign against HIV and AIDS led to a 23 percent reduction in cases since 2005, and the death rate decreased by 47 percent between 2005 and 2015.

“The estimates by country for the first time of government spending on HIV, which has been something that a lot of us working in the field have needed and wanted ... it’s in this report. They’re estimates, but they’re really the only comprehensive source of that that I’ve ever seen,” said Jennifer Kates, vice president and director of global health and HIV policy at the Kaiser Family Foundation. “This is filling a major gap in our toolkit that we need for policy and program.”

One of the causes for concern experts have identified is the disengagement young people have from the issue of HIV and AIDS, and the fact that they are not accessing services at a rate matching the growth of their share of the population. Dybul said that if the infection rate were to stay where it is today, as the 18 to 25-year old population doubles, the infection rate will double.

“Young people aren’t accessing services. And why we think all of a sudden they’re going to use self tests is beyond my comprehension. Every study shows that young people in Africa don’t think about HIV anymore. They think about other things,” Dybul said. “How we then fit HIV into a bigger picture — which is health, and economic growth and development, and particularly how we deal with young people — that could help us not necessarily get more money but have much more impact with the resources that we’re using.”

Total global health spending is not expected to decrease in the coming years, with the study predicting global health spending will reach $15.4 trillion in 2030. Tracking how money is spent is key, according to the report, to inform policy, evaluate results, and identify areas where more investment could improve health outcomes.

“This is just not how you combat an infectious disease. Infectious diseases spread,” Kates said. “There’s empirical evidence of what happens when you scale back. It’s very predictable, and so we’re not approaching this challenge in a way that works.”

Related themes
Health financing, Health systems, HIV prevention, Policy & governance, Sexual & reproductive health & rights, Testing & counseling, Treatment
global health, health financing, donor funding, development assistance, health spending