That money for HIV/AIDS efforts is not as plentiful as in previous years hardly comes as a surprise. UNAIDS notes that the global economic crisis appears to have put an end to a decade of funding increases by donors, after flattening out in 2009 for the first time, international AIDS assistance fell by 10% in 2010.
Nandini Oomman, director of the HIV/AIDS Monitor, which tracks AIDS spending at the Washington-based Centre for Global Development, admits that "we are in a bad situation" and faced with "less money and more [health] priorities". Moreover, non-communicable diseases have overtaken HIV/AIDS as the leading cause of death worldwide. Global and national leaders are now confronted with a "set of tough choices", she noted. As the world's largest donor to HIV/AIDS efforts, the United States contributes 54% of international AIDS financing, but the Centre for Global Development warns that in America's current political and fiscal climate, this level of support for AIDS funding may have reached a "tipping point" and "will be increasingly difficult to maintain in coming years".
Oomman pointed out that the US President's Emergency Plan for AIDS Relief (PEPFAR) was protected by legislation until 2013, so cuts in the funding mechanism may not be as deep as feared. "The real questions [about the future of PEPFAR] will open up in two years, when the US is faced with reauthorizing PEPFAR," she noted. In the meantime, the US global AIDS budget has been cut for the second year running - funding for PEPFAR in 2012 will be US$90 million less than the current allocation - and support for the Global Fund has flat-lined.
The cost implications are huge, particularly for countries such as Uganda that rely heavily on PEPFAR. According to Médecins Sans Frontières (MSF), less than half of the people needing treatment in Uganda get it, and PEPFAR currently supports 75% of all patients receiving ARVs in the country. International donors are increasingly requesting that Uganda look for domestic funds to support its response. Even countries such as South Africa that are better resourced and funds more than 80% of its treatment costs still receive substantial amounts from foreign donors. PEPFAR's shift from direct service provision to technical assistance has caused hospices and institutions that were providing ARVs to close down, and patients have been referred to a public health system that is overstretched and poorly equipped to deal with the growing numbers.
The UK's Department for International Development (DfID) is also cutting bilateral aid for HIV/AIDS projects in developing countries by 32%, from £59.9 million ($92 million) to £41 million ($64million), between now and 2015.
With many donor countries preoccupied with the economic crisis on their doorsteps and slowly starting to reduce their HIV/AIDS funding, the Global Fund remains a crucial player despite its latest setback. The amount of money that the multilateral body has made available since it was created in 2001 was "absolutely unprecedented. Organisations such as MSF have warned that many low-income countries with a high HIV/AIDS burden were relying heavily on money from the Global Fund to continue providing treatment as well as to scale up their programmes. Some countries have been unable to implement the most recent World Health Organization guidelines, which call for earlier initiation of treatment and better first-line drugs.
The Global Fund has also been hit by a crisis in confidence in recent months, after reports of grant mismanagement found by the Fund's Office of the Inspector General and the findings of a high-level independent review panel that recommended major changes to its accountability structures. With its future at stake, the Global Fund has been encouraging emerging markets to pick up the baton, but the reality is that financial backing from traditional donors such as America and the European countries is still vitally important. Oomman asks, "If I were an emerging market government, would I put my money in [an organization] which Western donors are pulling out of?"
Activists agree that although some countries with high HIV prevalence rates still can't afford to put a lot of money into their AIDS response, they cannot be completely absolved. The reality is that, sustainability of HIV&AIDs programmes depends on domestic funding with countries making the effort to at least lay down the enabling instruments that will grow over time and take over from donor funds when these funds dry up. In the words of one activist, "African governments are not doing enough at this stage, and it cannot be allowed to be ‘business as usual' in the face of this global economic crisis."