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01.12.2012 | Research article | Ausgabe 1/2012 Open Access

BMC Public Health 1/2012

Pattern and levels of spending allocated to HIV prevention programs in low- and middle-income countries

Zeitschrift:
BMC Public Health > Ausgabe 1/2012
Autoren:
Peter Amico, Benjamin Gobet, Carlos Avila-Figueroa, Christian Aran, Paul De Lay
Wichtige Hinweise

Electronic supplementary material

The online version of this article (doi:10.​1186/​1471-2458-12-221) contains supplementary material, which is available to authorized users.

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

PA participated in the design, conception and analysis of the study and drafted the manuscript, BG participated in the design of the study and analysis, CAF participated in the design, conception and analysis of the study, CA participated in the analysis of the study and drafting of the manuscript, PD participated in the analysis of the study and provided detailed comments on the first draft. All authors read and approved the final manuscript.

Background

In the third decade of the HIV epidemic, people are starting to adopt safer sexual behaviors, reflecting the impact of HIV prevention and awareness efforts [1]. There is evidence linking prevention strategies to reduction of incidence through behavioral change programs [2]. Also, there are reports of prevention program effectiveness and published estimates of the effectiveness of HIV prevention interventions in changing sexual behaviors [3, 4]. However, some studies have shown that countries often do not allocate resources in ways that are likely to achieve the greatest impact; countries with similar epidemic types and prevalence rates distribute resources in radically different ways [57].
The United Nations Political Declaration on AIDS called to expand prevention coverage by diversifying approaches and intensify efforts to end new HIV infections and reaffirm that prevention of HIV must be the cornerstone of national, regional and international responses to the HIV epidemic [8]. Governments also committed to re-double HIV prevention efforts by taking all measures to implement comprehensive, evidence-based prevention approaches, taking into account local circumstances, ethics and cultural values [8]. Even with gains in access to treatment, the number of people newly infected continues to outpace those that are put on treatment [9, 10]. Prevention remains the paramount challenge of the HIV epidemic and the modes of prevention are evolving with the results of the HPT 052 study [11, 12]. Even with gains in access to treatment and a global decline in the number of new infections, there were an estimated 2.6 million people newly infected with HIV in 2010 [1].
As the AIDS epidemic continues to evolve, revealing geographic variations between and within regions, countries are increasingly working to formulate responses specific to their particular contexts [13]. With the continuing scale-up of the national and international AIDS response, it is increasingly important to accurately track the origin of funds and how they are spent at the national level. This includes looking at whether countries are obtaining the maximum benefit and achieving expected outcomes from their AIDS resources [14]. The mapping of resource flows can help decision-makers monitor the effectiveness of their national programs and improve resource mobilization in underfunded areas. At the global level, this allows the international community to evaluate the status of its response and its financial accountability.

Methods

An analysis of reported HIV prevention expenditures from 69 low- and middle- income countries in 2008 was conducted, taking into account epidemic types, prevention spending categories and country income levels. A subset of 53 countries contained detailed information by spending category. All expenditures, by programmatic activity and HIV services, were cross-tabulated by source of financing and stratified by income level. Spending information from public and international sources was analyzed based on the National AIDS Spending Assessment (NASA) methods and classifications [15]. Total prevention spending was collected using United Nations General Assembly Special Session on HIV/AIDS (UNGASS) Indicator No. 1 reports [14]. This indicator reports on domestic and international spending on AIDS by country, broken down into spending subcategories.
NASA is a tool developed by UNAIDS to measure all the resources included in a country's national HIV response and is based on the national health accounts framework [16, 17]. In addition to reporting on UNGASS progress, the NASA methodology has been used to support countries in planning and monitoring their HIV activities. NASA applies standard accounting methods to reconstruct all transactions in a given country, 'following the money' from the funding sources to agents and providers, and eventually to beneficiary populations. These data are collected from every institution and organization that intervenes financially in the national response to HIV. And they are collected by the country's NASA taskforce and entered into a Resource Tracking System (RTS).
Countries were classified by national income level. Economies were divided according to their Gross National Income (GNI) per capita for the data collection year used, calculated using the World Bank Atlas Methods and grouped into four categories: low-income (US$ 935 or less); lower middle-income (US$ 936 - $3,705); upper middle-income (US$ 3,706 - $11,455); and high income (US$ 11,456 or more) [18]. All prices were converted into constant 2008 dollars.
Finally, countries were grouped by type of HIV epidemic using UNAIDS and WHO classification criteria [19]. This classification identifies three epidemic types-low level, concentrated and generalized-based on the current state of the epidemic and prevalence levels in each country. Low-level epidemics are defined as having prevalence below 1% in the general population. Concentrated epidemics are not yet generalized, but have expanded to greater than five percent among any sub-population group and are largely confined to most-at-risk populations-commercial sex workers (CSW), men who have sex with men (MSM) and injecting drug users (IDU).
South Africa is notably absent, due to the fact that they did not report their HIV spending in 2008.

Results

The 69 low- and middle-income countries with available data spent a total of US$ 5.1 billion on the AIDS response in 2008. Out of the 69 countries, there are 32 low-income countries, 26 lower middle-income countries and 11 upper middle-income countries. Prevention amounted to US$ 1.1 (+/- 22 million) billion of this total (21%); however, the majority of spending was focused on treatment and care (53%). Table 1 (Reported total and per capita prevention spending, proportion of international funding and overall HIV funding allocated to prevention by epidemic type for 69 countries, in order of per capita spending, 2008 (USD)) shows the absolute and per capita amounts spent on prevention by epidemic type, the level of financing coming from international sources, the proportion of overall HIV resources that were allocated to prevention and countries' ranking with respect to per capita spending.
Table 1
Reported total and per capita prevention spending, proportion of international funding and overall HIV funding allocated to prevention by epidemic type for 69 countries, in order of per capita spending, 2008 (USD)
Country
% HIV spending allocated to prevention
Total prevention spending (USD thousands)
% of total prevention spending funded by international donors
Per capita prevention spending
Ranking by per capita prevention spending
Low-level epidemics
Kyrgyzstan
63
5,547
88
1.01
17
Georgia
40
3,218
77
0.75
24
Cuba
12
5,543
25
0.48
35
Tajikistan
47
2,930
77
0.42
42
Azerbaijan
70
3,512
27
0.39
45
Iran (Islamic Republic of)
57
20,402
9
0.27
51
Lao People's Democratic Republic
31
1,571
100
0.25
55
Bolivia
40
2,178
60
0.22
56
Bangladesh
69
25,566
100
0.16
61
Morocco
37
4,685
71
0.14
62
Pakistan
68
9,709
24
0.06
65
Sri Lanka
66
1,030
100
0.05
66
Philippines
53
3,462
74
0.04
67
Egypt
35
2,601
50
0.03
68
Algeria
11
432
41
0.01
69
Concentrated epidemics
Republic of Moldova
70
8,966
59
2.28
6
Honduras
59
14,420
56
1.86
9
Costa Rica
33
6,480
9
1.39
11
El Salvador
21
8,338
25
1.35
12
Cambodia
38
19,929
79
1.31
13
Belarus
66
12,365
14
1.25
14
Chile
23
20,321
2
1.19
15
Mali
30
11,987
91
0.98
18
Argentina
14
35,216
12
0.88
22
Thailand
22
45,287
21
0.71
25
Dominican Republic
23
5,450
73
0.52
33
Ukraine
23
22,808
63
0.48
36
Peru
34
14,135
73
0.47
37
Mexico
19
50,606
1
0.45
39
Colombia
20
20,788
0
0.45
40
Viet Nam
36
39,344
89
0.44
41
Malaysia
45
11,000
0
0.39
44
Armenia
42
1,100
77
0.36
47
Gambia
11
563
100
0.34
49
Myanmar
47
15,546
94
0.27
52
Panama
7
922
77
0.26
53
Madagascar
42
5,003
75
0.26
54
Brazil
7
41,759
3
0.21
57
Venezuela
8
5,662
1
0.20
58
Niger
23
2,822
96
0.20
59
Paraguay
13
1,164
51
0.18
60
Somalia
18
1,088
100
0.12
63
Indonesia
50
24,703
61
0.10
64
Generalized epidemics
Botswana
9
29,766
66
15.37
1
Lesotho
12
9,869
67
4.84
2
Kenya
24
158,619
97
4.14
3
Rwanda
26
29,308
98
3.16
4
Gabon
38
4,542
8
3.11
5
Uganda
22
64,185
100
1.97
7
Mozambique
27
38,543
97
1.86
8
Malawi
19
20,598
98
1.42
10
Congo
35
4,118
100
1.12
16
Cote d'Ivoire
31
19,417
99
0.94
19
Togo
38
5,887
97
0.89
20
Burkina Faso
27
12,956
71
0.88
21
Guinea-Bissau
34
1,238
96
0.78
23
Eritrea
25
3,574
93
0.71
26
Central African Republic
15
3,031
92
0.70
27
Angola
38
12,215
16
0.68
28
Benin
28
5,745
81
0.65
29
Senegal
28
7,148
87
0.60
30
Cameroon
29
11,435
82
0.59
31
Burundi
22
5,736
81
0.54
32
Chad
38
5,323
100
0.49
34
Equatorial Guinea
12
329
100
0.47
38
Guinea
31
4,087
100
0.40
43
Nigeria
15
57,949
89
0.38
46
Ghana
22
8,307
83
0.35
48
Democratic Republic of the Congo
21
18,115
97
0.28
50
The study includes 15 countries with low-level epidemics, 28 with concentrated epidemics and 26 with generalized epidemics. Once adjusted by the size of their populations, countries with generalized epidemics showed higher average per capita spending on prevention-US$ 1.82 (Range .28-15.37) compared to US$ 0.68 (Range .10-2.28) in concentrated epidemics and US$ 0.29 (Range .01-1.01) in low-level epidemics. The greatest share of HIV resources going to prevention was in low-level epidemics, where 45% of funds went to prevention, compared to 20% in concentrated epidemics and 21% for generalized epidemics. Figures 1, 2 and 3 provide a breakdown of HIV spending by epidemic type and income level for all countries. Prevention spending patterns vary greatly, even among similar epidemic profiles and income levels.
Currently, prevention relies heavily on international donors. On average 38% of total financing for prevention came from domestic-public sources, in contrast to the 63% of total treatment expenditures that were funded domestically. International funding for prevention was highest in low-income countries, where it reached a median value of 95% (Range 24-100%), compared to 59% (Range 0-100%) in lower-middle income countries and 8% (Range 0-100%) in upper-middle income ones. In 46 countries, international sources were responsible for over 60% of prevention resources, with contributions of greater than 80% in 31 of those countries. The majority of these are low-income countries, although this group also included Equatorial Guinea.
Many of the countries benefitting from international assistance were from sub-Saharan Africa, which registered both the highest levels of per capita spending on prevention and the greatest proportion of resources coming from international donors. Sub-Saharan Africa received 90% of its prevention resources from international donors, compared to 62% in South and South East Asia, 54% in Eastern Europe and Central Asia, 27% in the Middle East and North Africa, and 15% in Latin America and the Caribbean. Per capita, sub-Saharan African countries spent US$ 1.01 on prevention, the highest among any other region. Eastern Europe and Central Asia was the second highest spender at US$ 0.67 per capita, followed by Latin America and the Caribbean at US$ 0.43, South and South East Asia at US$ 0.21 and the Middle East and North Africa at US$ 0.12.
In absolute terms, Kenya (US$ 158. 6 million), Uganda (US$ 64.2 million), Nigeria (US$ 57.9 million), Mexico (US$ 50.6 million) and Thailand (US$ 45.3 million) are the biggest prevention spenders. Botswana (US$ 15.37), which has invested heavily in its AIDS programs in recent years, has the highest per capita spending, followed by Lesotho (US$ 4.84), Kenya (US$ 4.14), Rwanda (US$ 3.16) and Gabon (US$ 3.11). Figure 4 is a representation of the 25 countries that spent the most on prevention and it shows both domestic and public sources of finance. Among the top 25 spenders, 12 relied on international sources for over 75% of their expenditures.
Table 2 (Total and proportional spending per prevention category in 53 countries, by epidemic type, 2008 (USD thousands)) presents expenditure by type of epidemic in relation to 23 prevention categories for the subset of 53 countries that provided detailed reports. Communication for social and behavioral change (16%), voluntary counselling and testing (14%) and prevention of mother-to-child transmission (13%) received the largest share of funds. These were followed by blood safety (10%) and prevention and treatment of STIs (6%). Notably, male circumcision and post-exposure prophylaxis both received less than 1% of overall prevention funding. Condom-related categories including, social marketing, public and commercial sector male/female condom provision, accounted for 7% of funding.
Table 2
Total and proportional spending per prevention category in 53 countries, by epidemic type, 2008 (USD thousands)
   
Low-level
 
Concentrated
 
Generalized
 
AIDS spending category
Total
% spending
Total
% spending
Total
% spending
Total
% spending
Communication for social and behavioral change
107,373
16%
5,058
12
35,040
11
67,275
21
Voluntary counselling and testing (VCT)
91,408
14%
1,665
4
32,589
11
57,154
18
Prevention of mother-to-child transmission
87,913
13%
854
2
34,980
11
52,079
16
Blood safety
69,542
10%
5,252
13
41,271
13
23,019
7
Prevention, diagnosis and treatment of sexually transmitted infections (STI)
40,937
6%
1,507
4
36,081
12
3,348
1
Prevention activities not disaggregated by intervention
37,617
6%
287
1
5,576
2
31,755
10
Community mobilization
33,128
5%
1,194
3
19,259
6
12,675
4
Condom social marketing
30,441
5%
4,340
11
6,834
2
19,267
6
Risk-reduction for vulnerable and accessible populations
25,777
4%
2,725
7
18,650
6
4,402
1
Harm-reduction programmes for injecting drug users
22,244
3%
6,275
15
15,451
5
518
0
Prevention - Youth in school
21,414
3%
1,902
5
7,034
2
12,477
4
Prevention programmes for sex workers and their clients
19,764
3%
2,555
6
13,513
4
3,696
1
Public and commercial sector male condom provision
15,817
2%
554
1
4,153
1
11,110
3
Prevention programmes in the workplace
13,296
2%
474
1
3,657
1
9,165
3
Prevention activities not elsewhere classified
10,881
2%
1,439
4
8,102
3
1,340
0
Programmes for men who have sex with men
9,887
1%
1,691
4
7,989
3
207
0
Prevention - Youth out-of-school
9,426
1%
671
2
6,779
2
1,976
1
Safe medical injections
6,727
1%
1,425
3
16
0
5,287
2
Prevention of HIV transmission aimed at people living with HIV
5,254
1%
363
1
3,160
1
1,732
1
Universal precautions
4,802
1%
537
1
4,185
1
80
0
Post-exposure prophylaxis
2,647
0.00
1
0
2,451
1
194
0
Male circumcision
1,089
0.00
0
0
922
0
168
0
Public and commercial sector female condom provision
1,060
0.00
9
0
722
0
329
0
Microbicides
21
0.00
0
0
21
0
-
0
Programs for the most-at-risk-populations (MARPS) each received 3% or less of overall funding, although proportional spending was higher in low-level epidemics. Overall, low-level epidemics spent 25% of their prevention budget on higher risk groups, compared to 12% in concentrated epidemics and just over 1% in generalized epidemics. This was due mainly to higher investments in harm reduction programs, which received 15% of prevention funds in low-level epidemics, compared to 5% of total resources in concentrated epidemics and less than 1% in generalized epidemics. Programs for MSM were allocated 4% or less of resources in each epidemic type, while initiatives targeting CSWs received 6% or less.

Discussion

The countries in this study spent just over a fifth of all resources for their AIDS response on prevention, providing a detailed picture of programmatic allocations of just over US$ 1 billion. While this analysis focused on prevention, these investments took place within the larger context of concurrent expenditures on treatment and care, orphans and vulnerable children, and program support and research, which brought total AIDS spending in 2008 to US$ 5.1 billion in the countries studied. Many of the prevention categories have low proportions of spending, but this does not necessarily mean that the spending is insufficient. This depends on the size of the target population and the amount that is spent. The recent Investment Framework proposes focused programs for high risk populations, elimination of HIV infections in children, reduction of risk through behaviour change, enhanced condom programs, treatment for people living with HIV and voluntary male circumcision in countries with high prevalence and low circumcision rates [20].
International funding is particularly prominent in prevention activities focused on MARPS, where it is the main source of overall funding, but it is likely that broader issues related to stigma, political will and human rights remain significant factors influencing domestic resource allocations. At least 42 countries in the study have laws criminalizing activities related to one or more MARPS [21]. Decreased donor contributions will result in reduced funding for these groups and domestic resources do not often make up the gap. Sustaining long-term preventive services in these populations could present a serious challenge, particularly in low-income countries.
Of the 26 countries with generalized epidemics in the study, 25 are located in sub-Saharan Africa, a region which accounts for an estimated two-thirds of the global HIV epidemic [22]. In these countries, it is essential to address sexual prevention, which have been reported as a key factor in the region's high levels of HIV transmission [9]. This requires simultaneous implementation of a variety of risk-reduction strategies. A key approach typically relies on messaging targeting a particular sub-population. In the 22 countries with generalized epidemics that provided a detailed breakdown of their spending, mass media campaigns, community mobilization and workplace prevention programs together accounted for 27% of prevention spending. VCT received 17%, while 20% was invested in PMTCT and 5% was put towards ensuring a safe blood supply. Communication for behavioral change was the top prevention spending category in generalized epidemics. Uganda has experienced success through its 1987 "Zero Grazing" campaign and appears to have reduced the percentage of men having multiple partnerships [23].
Currently, there is wide interest in using antiretroviral therapy as a means to prevent HIV transmission [24, 25]. Evidence from PMTCT programs and follow-up studies of discordant couples has demonstrated a significant reduction in HIV transmission through ART [26]. Preliminary results from the HPTN 052 study show that ART is 96% effective in preventing transmission to an uninfected sexual partner in discordant couples where the index case has CD4 counts between 350 and 550 [11]. It is therefore plausible that early antiretroviral therapy and wide coverage could reduce community viral loads and significantly reduce the number of new cases of HIV [27, 28]. HIV testing can act as an entry point to both effective prevention and treatment, and bridge the gap between these two approaches.
Increasing consistent use of condoms requires strategies that go beyond supplying condoms to increase demand and motivation for their use. Roughly, four percent of spending in generalized epidemics was allocated to the provision of condoms, while 3% of resources were used for condom social marketing activities. A few countries in the region did direct a large proportion of their prevention resources to condom-programs.
In generalized epidemics in sub-Saharan Africa male circumcision accounts for a small proportion of overall spending, with only four countries reporting expenditures in this area. Male circumcision has been shown to be highly cost effective [29, 30]. A randomized control trial found that male circumcision has the potential to reduce the risk of HIV in men by 60% [29]. The lack of spending in this area may be understandable, given that wide advocacy for this option really began in 2008. In June 2009, Population Services International received a five-year, US $50 million grant from the Bill and Melinda Gates Foundation to provide voluntary male circumcision services to 650,000 men in Swaziland and Zambia, while Zimbabwe has expanded a pilot program and is now aiming to circumcise 80% of its male population by the end of 2025 [30, 31]. There will likely be priority shifts and new trends in the future.
This study has several limitations; there is a lack of data to compare observed HIV spending levels with spending targets or populations at risk in the country. The data that do exist are highly unreliable and the authors determined that it was more instructive to present a global perspective of prevention than to compare spending to target population size. Also, expenditures are estimated using different sources of information and some countries lack comprehensive and regular expenditure records and accounting information systems. This analysis does not include out-of-pocket expenditures; although out-of-pocket spending has been found to vary from 23 to 68% of total health expenditures, the proportion that households divert to the purchase of condoms, HIV testing, clean syringes or other preventive interventions is unknown [32].

Conclusions

Substantial changes are needed to achieve a more targeted and strategic approach to investment in the response to the HIV/AIDS epidemic that will yield long-term dividends. Until now, advocacy for resources has been done on the basis of a commodity approach that encouraged scaling up of numerous strategies in parallel, irrespective of their relative effects [20]. The United Nations Political Declaration on AIDS commits to ensure that financial resources for prevention are targeted to evidence-based prevention measures that reflect the specific nature of each country's epidemic by focusing on geographic locations, social networks and populations vulnerable to HIV infection [8]. It is important that prevention and treatment be viewed not as competing interests, but as complementary activities that together provide the basis for combined prevention approaches that address each country's context. This overview of prevention spending may be a catalyst for further research into a more strategic use of prevention investments.

Acknowledgements

The authors would like to thank Carol Nicolls for her editorial assistance.

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

PA participated in the design, conception and analysis of the study and drafted the manuscript, BG participated in the design of the study and analysis, CAF participated in the design, conception and analysis of the study, CA participated in the analysis of the study and drafting of the manuscript, PD participated in the analysis of the study and provided detailed comments on the first draft. All authors read and approved the final manuscript.
Zusatzmaterial
Authors’ original file for figure 1
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Authors’ original file for figure 2
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Authors’ original file for figure 3
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Authors’ original file for figure 4
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