The Post-2015 Scenario
In September 2015, the UN General Assembly will be adapting a new set of development goals, with 2030 as its end-goal timeline. The proposed goals, currently referred to as Sustainable Development Goals (SDGs), are envisaged to define the UN Member States’ development priorities and financing in the next 15 years. Unlike the Millennium Development Goals (MDG) which included a specific goal for AIDS (Goal 6), the present articulation of the proposed SDGs, as agreed upon in the Open Working Group’s (OWG) final Outcome Document , include AIDS as one of the nine targets under the Health Goal. Overall, there are 17 proposed goals and 169 targets in the Outcome Document, which will be the main basis for the intergovernmental negotiation process at the 69th session of the UN General Assembly in September 2015.  The AIDS target statement reads:
3.3 by 2030 end the epidemics of AIDS, tuberculosis, malaria, and neglected tropical diseases and combat hepatitis, water-borne diseases, and other communicable diseases.
This iteration manifests a double-edged reality: progress has been achieved in many parts of the world in stemming the tide of new HIV infections and AIDS-related deaths; paradoxically, the global ‘de-prioritization’ of HIV in the development agenda could potentially undermine the future of the HIV response, threatening its sustainability and initial successes.
By the end of 2013, UNAIDS reported that 35 million people were living with HIV worldwide and new HIV infections were estimated at 2.1 million. These figures show a significant reduction in new infections, as well as AIDS-related deaths, primarily due to increased access to treatment by people living with HIV in the last decade. As of June 2014, around 13.6 million people were receiving anti-retroviral therapy, indicating strongly that the 15-million-people-on-treatment-target will be met by 2015.
With the HIV situation improving or plateauing in many countries, it has become a concern that there is less compulsion for governments to make it a priority issue. This presents serious implications with regards to resource allocation and programming, especially for prevention programmes for key populations and civil society organizations engaged in the HIV response.
HIV Financing: Is there money for HIV?
The prospect of sustained financing for HIV is dim. Resource tracking from UNAIDS notes that recipient governments of bilateral or multilateral HIV funding cannot expect donor governments, particularly from OECD countries, to continue or increase their contributions in the coming years. Funding commitments in 2013 fell to US$8.07 billion, a 3% drop from 2012, which was largely due to the United States, the largest donor country in the world, decreasing its annual commitments. In addition, HIV assistance from the U.K., France, Germany, and the Netherlands in 2013, which are historically the four largest donors after the U.S., were all either at or below levels reached in previous years.
Recent financing trends reveal that donor countries are shifting from bilateral to multilateral funding. An example of this is the increased contributions to the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund). However, with the New Funding Model (NFM) of the Global Fund, low and middle-income countries will become ineligible for funding and this will have serious implications on countries, which do not have a high national HIV burden, but have concentrated epidemics among key populations. It also means that the money will be apportioned for the three diseases, which could result to less allocation for HIV.
In Asia and the Pacific region, only twenty-four per cent of the total funding for HIV and AIDS from 2009-2012 was used for prevention, and of this, only 35% was spent on programmes for key populations. The biggest share of the resources was spent on treatment and care (47%), with programme management and administration coming in third with 18%. Spending on treatment is necessary to curb AIDS-related deaths, however, a disproportionate allocation that deprioritizes prevention, especially among key populations, may well lead to increases in new HIV infections, overturning the initial gains in the HIV response.
In many countries in the world, prevention is funded largely by external sources, while treatment and care is now increasingly being sourced from domestic resources. The emphasis on domestic financing is underscored by the inclusion of ‘Closing the Resource Gap’ as one of the ten targets emanating from the 2011 Political Declaration on HIV and AIDS. In the last five years, considerable efforts were undertaken by UNAIDS to track countries’ HIV expenditures, investments and assistance, with the view that without increased investment, the HIV prevention and treatment targets will not be met.
The push for domestic spending sends a message to governments to not abdicate on their duty to fulfill the health needs of their citizens, particularly key populations who are often marginalized and unable to access health services and information. However, while evidence suggests that community-led HIV programmes and services are most effective in ensuring that hard-to-reach populations are able to have access to these services, community-based networks and organizations running these services do not necessarily have access to government funding. In many instances, prevention programmes are largely externally-resourced, with the Global Fund as one of the main donors. In Asia and the Pacific, 95% of funding for MSM and 94% of funding for sex workers are externally sourced. Thus, the threat of reduced funding from international donors could have a chilling effect on the sustainability of community-led programmes. There is also less optimism that governments will pick the tab for community-led programmes, given the often testy relationship between government and civil society.
Currently, there are discussions around various schemes and approaches to sustain HIV financing, which are envisaged to respond to the funding threats. These include “transition funding”, integration into national health financing systems, such as through social health insurance, or in sexual and reproductive health (SRH) programming, and inclusion in universal health coverage, among others. The concerns raised against HIV exceptionalism have also propelled the discussion towards integration, as having stand-alone, siloed HIV responses are deemed as unsustainable in the long term.
While the modalities of transition funding are still being discussed, there is considerable apprehension that civil society and community networks, especially among key populations, would bear the consequences of reduced resources the most. Apart from this, funding to address critical enablers such as reduction of stigma and discrimination, promotion of human rights, inclusion of gender and sexuality in the response and engagement of civil society and communities, would be the first to get cut off. UNAIDS notes that funding for human rights accounts for less than 1% of the US $18.9 billion spent on the overall HIV response in 2012.
The inclusion of HIV in UHC has been championed by the World Bank and the WHO, as a means to ensure that the HIV response is ‘mainstreamed’ and integrated into national health systems. The WHO defines UHC as “ensuring that all people obtain the health services they need, of good quality, without suffering financial hardship when paying for them.” Voices concerned and critical of UHC note that there is a risk that countries will seek to advance progress towards UHC by focusing on easier to reach populations, while excluding more marginalized populations including people living with and those most affected by HIV, such as men who have sex with men, sex workers, people who use drugs and transgender people. Thus, a parallel approach of addressing inequities and elimination of stigma and discrimination needs to be undertaken in order for UHC to work.
New Targets for 2030
With the post-2015 process already rolling, UNAIDS has proactively gone ahead to develop its new round of treatment targets. Targets are essential in measuring achievements, as well as gaps and failures in the HIV response. In light of changing political and economic realities, scientific advancements in bio-medical research and heightened community engagement in the HIV response, governments need to ensure that they are able to take these contexts into account, as they move towards a future that requires considerable investment from their end. Ending AIDS in 2030 is now deemed as achievable, but the means of implementation have not yet been spelled out concretely in terms of global and national strategies and indicators.
The first group of targets to be developed for treatment, also known as 90-90-90 are as follows: 
- By 2020, 90% of all people living with HIV will know their HIV status.
- By 2020, 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy.
- By 2020, 90% of all people receiving antiretroviral therapy will have viral suppression.
These targets, along with WHO’s recently launched treatment guidelines, i.e., initiation of treatment at 500 CD4 count or upon diagnosis if coming from a key population and practicing riskier behavior, are meant to scale up treatment and stem the tide of new infections. Discussions are ongoing on how these guidelines will be rolled out, with due consideration of current resource limitations and potential HIV funding glut. It also brings to light the challenges brought about by intellectual property barriers, which makes life-saving ARV drugs unaffordable in many countries. There are also persistent concerns about governments being able to ensure that they adhere to rights-based principles and approaches and that no violation of rights or coercion occurs throughout the entire cycle of HIV programming, in the desire to meet the targets.
Fast-Tracking the end of AIDS by 2030
On occasion of the 2014 World AIDS Day, UNAIDS has launched a report on ‘fast-tracking the end of the AIDS’. The report lays out resource requirements of countries to enable them to meet the goal of ending AIDS. Low-income countries will require US$ 9.7 billion in HIV funding, lower-middle-income countries will need US$ 8.7 billion, and upper-middle -income countries will require US$ 17.2 billion in 2020. The emphasis on investment for AIDS is underpinned on the premise that if the resources are reduced, there would be severe cost implications for HIV programming beyond 2020.
Despite the wealth of information on what is needed to overturn the HIV epidemic, global commitments and actions remain uneven. While civil society and communities strive to engage meaningfully in the response, without secure HIV financing from domestic and external sources, fast-tracking or ending the AIDS epidemic will be stalled. This entails that governments are able to mobilize resources through their budget allocations and have the fiscal space to do so. However, national budgeting is a highly political process that entails multiple levels of negotiations and trade-offs involving legislative and executive branches of government. This then requires vigilance on the part of civil society and communities to understand the budget process, in order to intervene effectively. It also entails monitoring government expenditures, in order to track whether the budget allocations are efficiently and properly spent.
The case for addressing HIV and AIDS has long been established. Not only will it lead to positive health outcomes, but will also contribute to fulfillment of human rights, achievement of gender equality and justice and tackling of social and economic barriers. Sustained investment in HIV programming, as a stand-alone response or integrated into existing health systems, from domestic or external sources, for treatment, prevention and enabling environment, will be requisite in enabling the end of AIDS.