Asia can afford universal access for AIDS prevention and treatment
Komatsu, Ryuichia; McLeod, Rossb; Sarkar, Swarupa; Siripong, Nalync; Gupta, Indranid; Tangcharoensathien, Viroje; Brown, Timc; Jeugmans, Jacquesf; Avila-Figueroa, Carlosg; Atun, Rifata,h
aThe Global Fund to Fight AIDS, Tuberculosis, and Malaria, Geneva, Switzerland
beSYS Development Pty Ltd., Sydney, New South Wales, Australia
cEast-West Center, Honolulu, Hawaii, USA
dInstitute of Economic Growth, University of Delhi, India
eInternational Health Policy Program, Ministry of Public Health, Thailand
fAsian Development Bank, City of Mandaluyong, Metro Manila, Philippines
gFinancing and Economics Division, UNAIDS, Geneva, Switzerland
hImperial College London, London, UK.
Correspondence to Ryuichi Komatsu, Team Leader, Strategic Information, The Global Fund to Fight AIDS, Tuberculosis, and Malaria, Geneva, Switzerland. E-mail: Ryuichi.komatsu@TheGlobalFund.org
This paper draws on published reports, data from the Global Fund to Fight AIDS, Tuberculosis, and Malaria and the Asian Development Bank, and analysis by the Commission on AIDS in Asia to estimate financial resources required to achieve universal access for HIV in low-income and middle-income countries of Asia. It explores optimal use of available resources to mount effective response to AIDS in Asia against an uncertain economic climate. Although there is global commitment to tackle the HIV pandemic, available financing falls short of minimum requirements to achieve universal access to prevention and treatment. To support essential HIV priorities in Asia, the Commission on AIDS in Asia estimated annual resource needs to be US$ 3.1 billion. Yet, in 2007, according to one study, estimated total public spending on AIDS in 14 major Asian countries was only US$ 0.9 billion. Hence, scarce resources need to be carefully applied to address the concentrated HIV epidemics in Asia and achieve universal coverage by prioritizing investment in high-impact interventions to maximally avert new infections and deaths, intensifying multisectoral efforts through catalytic financing that mainstreams HIV interventions into existing services, particularly for low-impact prevention programs, and ensuring countries with growing economies mobilize increased amounts of domestic funding to match international financing.
The turn of the millennium was marked by an increased global commitment to tackle the HIV pandemic . The United Nations General Assembly, recognizing HIV as a significant barrier to development, pledged to contain the spread of the disease in the Millennium Development Goals in 2000  and endorsed the Declaration on HIV/AIDS at its Special Session (United Nations General Assembly Special Session) in 2001 . Similarly, at their 2005 summit, the G8 called for universal access to AIDS treatment by 2010 [4,5], a pledge expanded that year at the United Nations World Summit to include universal access to prevention, treatment, care, and support for AIDS, followed by the United Nations General Assembly's Political Declaration on HIV and AIDS in 2006, following discussions on universal access at the United Nations High Level Meeting on AIDS . Global resource needs for AIDS were estimated at US$ 9.2 billion for 2005 [7–10], US$ 14.9 billion for 2006, US$ 18.1 billion for 2007, and US$ 22.1 billion for 2008 .
International donor financing for HIV increased from US$ 1 billion before 2000 [9,10] to US$ 8.7 billion in 2008 (with US$ 6.7 billion disbursed) , with total available global funding totaling US$ 13.8 billion from domestic (52%), bilateral (31%), multilateral (12%), and philanthropic (5%) sources . This included funds from the United States President's Emergency Plan for AIDS Relief, which committed US$ 15 billion through to 2008, largely for programs in Sub-Saharan Africa; the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund) emphasizing performance-based funding [13,14] and country ownership, investing US$ 5.7 billion by end of 2009 (http://www.theglobalfund.org) , and the World Bank's multicountry HIV/AIDS Program providing US$ 1.8 billion between 2000 and mid-2009 .
Yet, increased funding for HIV falls far short of that needed for achieving universal access, estimated by The United Nations Joint Programme on HIV/AIDS (UNAIDS) to reach the 2010 country-specific AIDS targets of US$ 25.1 billion, with US$ 11.6 billion needed for prevention and US$ 7 billion for treatment [including provision of antiretroviral therapy (ART) to 6.7 million people in 2010] .
Financing trends for HIV in Asia
Resource needs estimates in the region
On the basis of targets set by countries, UNAIDS estimates that US$ 7.5 billion will be needed to finance the HIV response in low- and middle-income countries of Asia and the Pacific in 2010 . This resource needs estimate is based on the number of people requiring services, the targeted coverage, and unit costs for the services . The number of people in need of treatment may be estimated from disease epidemiology , although revisions of treatment eligibility criteria significantly change estimates . Treatment costs are a combination of the fraction of need met and the costs of associated medical care, but are heavily influenced by the costs of drugs, in particular the cost of second-line drugs that far exceed the cost of first-line drugs . Changes to drug regimens that lead to inclusion of costly drugs substantially increase unit cost of treatment [20,21]. Prevention costs are determined by the size of at-risk populations, targeted coverage levels, and the unit costs of activities. Unit costs may decrease with coverage scale-up, but may also increase as target populations become more difficult to reach. The breakdown for UNAIDS’ estimate is publicly available for 2007 (Table 1) . In the Asian context, where current prevalence levels remain low, 70% (US$ 4.4 billion) of the estimated needs (US$ 5.5 billion) is for prevention. Treatment accounts for only 12% (US$ 0.76 billion) of the resource needs.
The Commission on AIDS in Asia recognized that a substantial fraction of the estimated resource need was for programs with limited prevention benefit in Asia, for example, school-based programs for youth and blood safety , where the HIV epidemic is concentrated mainly among most-at-risk populations (MARPs) such as female sex workers and their clients, people who inject drugs, and men who have sex with men (MSM) [23–25]. Hence to avert new infections, investments should prioritize prevention among MARPs. The standard package for MARPs included peer education; prevention that includes condom distribution and management of sexually transmitted infections (STIs), provision of clean injecting equipment for people who inject drugs, and substitution therapy using methadone or buprenorphine for 30% of this group; creation of enabling environments; and building capacity of nongovernmental and community-based organizations working with these groups . In Asia, programs targeting sex workers have resulted in an 80% rise in condom use and large reductions in the prevalence of STIs [26–29]. Programs targeting people who inject drugs halved the frequency of needle sharing, reduced the fraction of all injections shared among those who continue injecting by nearly 40%, and diminished injection frequency . These high-impact prevention interventions along with essential treatment, impact mitigation, and small investments in enabling environment support required only US$ 3.1 billion annually . Of note in Table 1 is the lesser emphasis on high impact to other prevention strategies by UNAIDS compared with Commission estimates (Table 1).
Potential to increase available financial resources in Asia
A study  conducted in 2008 on the financing needs and availability of 14 Asian countries (Bangladesh, Cambodia, China, India, Indonesia, Laos, Malaysia, Myanmar, Nepal, Pakistan, Philippines, Sri Lanka, Thailand, and Vietnam), where almost all HIV-infected persons in low-income and middle-income Asian countries live, estimated total spending on HIV to be US$ 896 million in 2007 (Table 2a). This represents a rather low per capita investment of US$ 0.26. Between 2004 and 2007, external funding increased by US$ 292 million, doubled the increases seen in domestic funding of US$ 143 million (Table 2a).
By the end of 2009, the Global Fund had approved US$ 3.8 billion (Table 2b) to fight HIV in the Asia and Pacific region, with US$ 1 billion disbursed (Table 2c). This represented 19% of the US$ 5.7 billion disbursed worldwide for AIDS programs.
In Asia, between 2004 and 2006, total national health expenditures grew by US$ 43 billion, 150-fold greater than that for HIV expenditure (Table 2a). A recent analysis  also indicated increases in government expenditure on health in Asia. Thus, increased international funding for HIV is not negatively impacting overall health financing , refuting arguments that investments in HIV crowd-out investments in other health areas .
The impact of the global economic crisis on health financing in Asia is unclear. Although no adverse effect on AIDS treatment is observed, social sector funding may fall in line with declines in government budgets .
Current finances fall short of estimated resource needs. Available funding of US$ 896 million in 2007 in the aforementioned 14 countries is only 29% of the priority resource needs of US$ 3.14 billion (Table 3). Although the Commission on AIDS in Asia estimated US$ 1.34 billion for prevention among MARPs, US$ 359 million for other prevention, US$ 761 million for treatment, and US$ 676 million for other areas, actual expenditures for MARPs were US$ 81 million, US$ 247 million for other prevention, and US$ 283 million for treatment. The funding gap is much wider for prevention among MARPs (94%) than for other prevention (31%) and treatment (64%) (Table 3). The disproportionately low spending on MARPs, with the potential to reverse the epidemic, contrasts with the substantial funding of US$ 247 million (28% of funds) allocated to other prevention activities for lower risk populations with limited impact on the epidemic.
Similarly, the Unified Budget and Workplan of UNAIDS cosponsors showed that resource allocations did not adequately provide for optimal HIV prevention programming, with 6% of the funds targeting prevention among high-risk young people and 94% for low-risk youth compared with potential 95% of infections averted among high-risk young people, whereas only 5% among low-risk young people . Significant funding shortages require evidence-based allocation of existing resources to programs with proven effectiveness and impact to reverse the HIV epidemic. In Asia, this means prioritizing investment in prevention among MARPs rather than following the priorities of individual organizations.
Targeted investment to achieve universal access in Asia
Asia can afford universal access to AIDS prevention and treatment, if there is prioritized investment in high-impact prevention for MARPs to maximally avert new HIV infections; intensified multisectoral efforts to incorporate HIV prevention and care into existing programs and services, especially for prevention among populations at low-risk or for low-impact prevention services; and increased domestic funding in countries with growing economies to match and exceed investments from international sources.
First and foremost, investments should prioritize interventions with greater effectiveness in averting new HIV infections and those improving people's quality of life so as to maximize returns. Antiretroviral treatment reduces morbidity, enables people infected by HIV to remain productive, lessens demand for healthcare services, and keeps families together, thereby averting costs of orphan care.
Modeling of the Asian epidemics has clearly shown that some interventions, though less expensive, yield high benefits in terms of preventing future HIV infections (Fig. 1) . For example, interventions among female sex workers and their clients cost less and can prevent larger numbers of HIV infections than interventions, which target the general public. This was demonstrated by an empirical study in Andhra Pradesh, India, which demonstrated how focused investment based on integrated analysis and evaluation can reduce HIV infections [36,37].
Interventions can be classified, according to the level of overall effectiveness in terms of disability-adjusted life years (DALYs) saved and the cost per DALY saved, into four broad categories: low cost–high impact, low cost–low impact, high cost–high impact, and high cost–low impact .
In the Asian context, prevention for female sex workers and their clients, harm reduction programs for people who inject drugs, and prevention for MSM are examples of low-cost–high-impact interventions. These interventions can avert hundreds of thousands of infections and save millions of DALYs in the medium-to-long term (10–15 years). Conversely, low-cost–low-impact interventions include general awareness through mass media and sex education in schools. Such longer term programs, though important, are likely to avert fewer HIV infections, but when implemented at the expense of programs for at-risk populations, create huge opportunity costs.
High-cost–high-impact interventions include ART, which prolongs life and averts death, with major benefits to HIV-affected persons and their families. Scale-up of ART in Asia has been impressive to support over half a million people on treatment . Prevention of mother-to-child transmission can effectively avert infections in newborns, but in low-prevalence settings, program maintenance and the cost per case is high.
High-cost–low-impact interventions such as blood safety and universal precautions are among the most costly, but prevent the fewest number of infections. This makes them poor candidates for investment exclusively from AIDS budgets but should be resourced from general health system resources.
High-impact interventions should be the top priority for national AIDS programs. Low-impact interventions may also be important but, given limited resources, should not be funded at the expense of the high-impact interventions, which actually have the potential to reverse the epidemic if implemented with high coverage. Unfortunately, generally in Asia, low-impact interventions have received a major portion of prevention resources instead of high-impact interventions .
Second, multisectoral efforts should be intensified using program resources from multiple sources, including limited catalytic financing from the national AIDS budget. These efforts will generally target prevention activities among lower risk populations, for example, life skill training and basic HIV knowledge as an integral part of basic education. However, support from the national AIDS budget early on for the development of an AIDS curriculum could encourage the education sector to assume full responsibility for these programs with their own resources. High-impact prevention may be fully funded by the AIDS budget even when implemented by ministries other than health (e.g., training of police for harm reduction). Prevention efforts in Thailand became more effective with multisectoral efforts, whereby various ministries allocated their own direct resources for the national AIDS response to supplement those of the public health ministry .
Third, Asian countries must increase their investments in HIV as well as health. The domestic contribution to AIDS responses in the region is low. Asian health budgets as a proportion of overall public expenditure were among the lowest in the world . This is particularly true for countries with rapidly growing economies such as India and China. Thailand has substantially increased domestic investments in HIV but more could be done for prevention. If these three countries, which share three quarters of HIV infections in Asia, could over time become self-supporting, currently available international resources could cover most of the remaining needs in Asia. A recent study has shown that middle-income countries with expected low prevalence (less than 1% of adults) in 2030, such as China, India, Thailand, and Vietnam, have strong chances of fully financing their AIDS response, by devoting less than 0.2% of their gross domestic product (GDP) to AIDS programs, without any external financing [40,41]. Unfortunately, the increase in domestic HIV funding in Asia (only 68% from US$ 209 million in 2004 to US$ 352 million 2007) has not matched that in external funding (116% from 2004 to 2007) (Table 2a).
Toward sustainable responses
Despite disproportionately low allocation of resources to low-cost–high-impact interventions in many Asian countries to date, an analysis of proposals approved by the Global Fund provides encouraging indications of growing recognition of the need to address prevention for MARPs. The share of high-impact interventions targeting these populations in the proposals approved as part of the Round 8 in 2009 was substantially larger than that in Round 6 (Table 4) (http://www.theglobalfund.org).
This is an encouraging development, as securing increased funding for more cost-effective programs from international financial institutions may be a pragmatic way to rapidly mobilize resources for interventions neglected in the past, help build government commitment, and catalyze incorporation of these interventions into national systems. To sustain this shift, country-level partners, especially those working with MARPs, should be engaged in developing proposals that are based on scientific evidence with appropriate and well justified priorities. In turn, this requires countries in Asia to strengthen their strategic information systems  to provide a foundation for robust, evidence-based priority setting and prioritizing interventions for MARPs.
To promote universal access to intervention benefits at the population level, it is critical to develop a coordinating forum that makes resource allocation decisions based on evidence and seeks input from various partners and stakeholders. A good example of such a forum is the Global Fund's Country Coordinating Mechanism, which requires representation of civil society and in particular people living with the disease. However, engagement of affected communities is still inadequate. For sustainable impact, greater engagement of community-based organizations and nongovernment organizations working with MARPs and involving people living with HIV is critical to ensure access to health services for MARPs.
Further research to generate region-specific knowledge, understand current resource demands and availability, and to inform future directions is essential. UNAIDS has an important leadership role to play in this regard. There is scope for improvement and to further catalyze transparency and donor coordination . Strategic information and analytical capacity must be strengthened to regularly analyze needs, cost-effectiveness of interventions, and to provide evidence for decision-making [42,44–46]. Resource needs estimates should be periodically updated because costs, epidemiology, and behaviors change over time [45,47]. National AIDS Spending Assessments help provide clarity on donor funding and enhance understanding of investments in service delivery and technical assistance by international agencies . In particular, strategic information systems should be strengthened to capture civil society and household expenses, important sources of expenditure on which too little information is available [49,50].
Long-term financial sustainability requires investment in high-impact interventions using both domestic and international financing. Several economically strong countries in Asia can move over the next years to finance most of their AIDS response from domestic resources. Investments in low-impact programs through multisectoral actions should be coordinated to ensure mainstreaming of the response to reduce duplication of efforts .
However, even with these actions for years to come, large funding gaps will remain for most low-income countries. The economic crisis demands exploration of innovative mechanisms to raise additional funding, for example, through inclusion of HIV prevention, treatment, and care in nation-wide health insurance systems, as has been achieved in Thailand . Until then, international financing needs to be sustained to expand HIV prevention programs and coverage among MARPs to the levels that can reverse the regional pandemic.
The authors wish to acknowledge the Asian Development Bank for their support for the 2008 study on funding needs and availability; Roger Detels and Michael Hahn for discussion and comments; Donna Lee for data assistance; and Sheena Sullivan, Veronique Collard, and Pauline Brocard for comments on and editing versions of the manuscript.
The views expressed in this paper are those of the authors and do not necessarily represent the position of the Global Fund to Fight AIDS, Tuberculosis and Malaria.
Conflicts of Interest: None.
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