HIV and the Financial Crisis Academic Council Debate on the Financial Crisis and Public Health Robert Greener, April 30, 2009

Magnitude of the Epidemic 33.2 million living with HIV –67% in sub-Saharan Africa 2.5 million new infections per annum 2.1 million deaths per annum –number infected still growing More than 3 million on ARV treatment Most infections are in low and middle- income countries

The World of HIV © Copyright 2006 SASI Group (University of Sheffield) and Mark Newman (University of Michigan).

The World of Income © Copyright 2006 SASI Group (University of Sheffield) and Mark Newman (University of Michigan).

Prevalence and Impact – the “long waves” of HIV T.Barnett, A.Whiteside

The UNAIDS Cosponsors

The Financial Crisis (or is it an economic crisis?) There is general consensus within (and beyond) the UN system on the key elements of the crisis –The crisis is affecting both advanced and developing countries –Financial conditions facing developing countries have deteriorated sharply, and the crisis will have long- term implications for them –The challenge is to protect or expand critical expenditures in the social sector – safety nets, human development and infrastructure –There is a strong need to expand assistance to developing countries to protect these expenditures and prevent the erosion of progress in reducing poverty

Domestic Resources In low and middle-income countries Private Sector – and workplace Individuals – Out of pocket and insurance -Not well known Domestic Public Sector Government Budgets in low and middle-income countries External Resources From high-income countries Private Foundations Direct Bilateral Cooperation Targeted and Sectoral Aid Budgets Multilateral Institutions GFATM, UN, EU Global Innovative Mechanisms South-South Cooperation Triangular Cooperation Regional Cooperation Public Sector Bilateral Donors Private Sector

What will happen to domestic funding for HIV? Most of the domestic funding is within middle-income countries such as Brazil, South Africa and Thailand Evidence for the past is that social spending has been reduced during times of economic downturn This picture is not uniform, and cannot be used as a guide for the future – social spending is a policy choice.

ODA and GNI in OECD fall of 4.9% per annum for 5 years during strong GDP growth (3.2% p.a.) 5-8 years to recover

Resource Availability for HIV

Estimated Resource Needs

Key Issues for UNAIDS What are the vulnerability implications of: –Increasing unemployment –Decreasing remittances –Increasing poverty and food insecurity –Possible wider effects, such as deteriorating governance What are the long-term implications of making bad choices now?

The Impact on AIDS The global economic crisis threatens to reverse gains in health and poverty alleviation in developing countries These effects are likely to be magnified by the impact of the crisis on the HIV epidemic, especially in the high HIV prevalence countries in sub-Saharan Africa

Country Vulnerability Vulnerability to the Crisis Undiversified domestic economy High level of poverty Low fiscal capacity Low institutional capacity –Undeveloped social protection systems Vulnerability of HIV Programmes HIV resource needs in relation to GNI

Current Perceptions Information collected in late March 2009 from 69 countries (in which 3.4 million people are under treatment) shows that: –In 12% of the surveyed countries, the crisis is already impacting treatment programmes. –In 32% of the countries—home to 61% of those under antiretroviral treatment—an impact is expected this year.

The risks of reduced treatment Increased mortality and morbidity Unnecessary death and disease (including increased tuberculosis) due to AIDS Greater transmission risks as people off treatment become more infectious Higher financial costs Interruptions of treatment make treatment failure more likely, requiring use of costly second-line regimen drugs Increased burden on health systems. More HIV- related illnesses, and pressure on health services at a time when their budgets are being cut Reversal of economic and social gains. Consequences for households, and costs to businesses and public agencies.

The risks for prevention If treatment programmes are protected, there is a risk that funding for prevention will be cut If this happens, it will lead to more AIDS illness and treatment need in the future –Higher costs of treatment programmes –Welfare impacts for households

Core Challenges Universal Access: To maintain and expand HIV programmes To increase the effectiveness with which resources are used To secure long-term sustainable financing for HIV from both external and domestic sources

Challenge of Universal Access Access to prevention, treatment and care has produced measurable results Estimated resource needs to continue the scale up to Universal Access will require almost double what is currently available (about $25 bn. per annum) Most of these increases will have to be met from international aid funding

The Challenge to Increase Effectiveness This challenge is highlighted by the financial crisis Money from all sources must be used as effectively as possible for prevention, treatment and impact mitigation Programmes must be designed to target the root causes of vulnerability and impact

Challenge of Sustainable Financing The AIDS response is a core pre-requisite for the Millennium Development Goals Countries will need to reprioritize their spending towards social goals such as health, while also tapping a diverse and innovative mix of financing sources The international community will need to maintain resolve and urgency for all of the MDGs