Action plan to reverse destructive HIV financing trends in middle-income countries

Despite commitments from governments to “leave no one behind” across all health and development work, funding from donors for HIV and TB responses is decreasing and governments are not living up to their obligations to ensure the right to health of their citizens. The first and hardest hit are people living in middle-income countries (MICs), where donor governments and multilateral funding mechanisms are withdrawing financial support. HIV and TB primarily affect key populations in these countries—sex workers, men who have sex with men (MSM), people who use drugs, the incarcerated, migrants, and poor women and girls. Unless action is taken, millions will suffer and die. This document serves as both a call to action and a plan for coordinating communications and activities to stop this attack on people’s lives and human rights.

With few exceptions, most countries in the developing world are caught between two opposing pressures. On the one hand, the Joint United Nations Programme on HIV/AIDS (UNAIDS) has prioritized achievement of the “Fast-Track” targets, which focus on rapid scale-up of access to HIV prevention and quality HIV treatment, including the gold standard viral load diagnostic tool. On the other hand, donors are cutting back on external HIV financing and national governments are failing to absorb HIV and TB programmes (which are often needed in particular by criminalized and marginalized groups) into their health systems.

To put it simply, most countries, especially MICs, are being asked to do more with less—an impossible task and unfair responsibility in countries that still host some of the poorest populations in the world. The inevitable consequences include overstretched public health systems and precarious treatment and prevention services that are stretched too thin. That is a recipe for disaster, or, more precisely, for losing what limited control has been gained over the HIV epidemic. If public health systems fail to cope with dual pressures of Fast-Track and “do more with less”, the inevitable results will be drug resistance, drug stock-outs, lack of sufficient prevention and support, and limited ability to reach all clients in need at all stages of the HIV and TB prevention, treatment and care cascades.

Upper-middle-income countries (UMICs) and other MICs, especially those with low disease burdens but concentrated epidemics among key populations, fare the worst because most donors are shifting financing priorities to lower-income countries severe epidemics. The reasons given typically include the need to direct funds to countries and contexts with the most limited resources and capacity. That rationale sounds reasonable from a theoretical or conceptual level, but makes little logical sense from an epidemiological or practical standpoint. For one, countries are categorized as middle or lower or upper income, or one of various gradations in between, solely on the basis of per capita income. That factor is notoriously imprecise in terms of identifying where the most pressing needs are. MICs remain home to the majority of poor people in the world. Data published in 2012 identified that 80% of the world’s poorest people—those who live on less than  $2 per day—are now living in MICs. The burden of the three diseases is concentrated in MICs, which currently are home to about 57% of all people living with HIV, 72% of those living with active TB, and 54% of malaria cases annually. MICs’ share of the world’s people living with HIV is projected to rise to 70% by 2020. About 60% of worldwide cases of multidrug-resistant TB (MDR-TB) are in just four countries, all of which are MICs: India, China, Russia and South Africa. In addition, focusing solely on countries that contribute the most to global disease burden means ignoring epidemiological realities—including countries with concentrated epidemics and/or countries with high national burden but smaller population size.

These figures underscore a retreat from principles that advocates and global leaders fought for years to place at the centre of HIV and broader development policies and programming. In 2001, for example, then–UN Secretary-General Kofi Annan noted that “we must all remember that while HIV/AIDS affects both rich and poor, the poor are much more vulnerable to infection, and much less able to cope with the disease once infected.” Fourteen years later, as noted in this document’s introductory quote, the 2030 Agenda for Sustainable Development, which laid the basis for the Sustainable Development Goals (SDGs), pledged that “no one will be left behind” as we seek to “free the human race from the tyranny of poverty and want and to heal and secure our planet.”

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