The fight against HIV and TB is at a critical juncture

For the first time in a decade, international and domestic funds available to fight HIV and TB declined in 2018, putting further pressure on countries facing these epidemics. As donors to the Global Fund to Fight AIDS, Tuberculosis and Malaria gather in the French city of Lyon this week to fill the envelope for the next three years, a report by Médecins Sans Frontières/Doctors Without Borders (MSF) warns about the current funding decline and its impact on patients.

“I've been living with HIV for 15 years,” says Laetitia from Central African Republic. “If I'm still in good health today, it's thanks to my antiretroviral treatment. But for several months we’ve had no medicine. We don’t know how we will survive. We just don’t know…”

Laetitia, 32, is just one of many patients impacted by the challenges to prevent and treat HIV. Her country, like so many others, does not have enough international support to tackle the disease, and has difficulty mobilising more domestic resources. Central African Republic is one of the poorest countries in the world, in the grip of armed conflict and with huge humanitarian needs.

"The recent global downward trajectory in funding comes at a critical juncture for the HIV and TB response," says Dr Mit Philips, health policy analyst at MSF. "While gains made in countries such as Mozambique are at significant risk of backtracking, there is an even higher risk that countries in regions such as West and Central Africa, which are already lagging behind in the HIV and TB response, may see the situation deteriorate even further." 

A decline that makes victims

According to UN figures, domestic and international funding for HIV programmes fell by US$1 billion in 2018, while the funding gap for TB programmes widened further, reaching US$3.5 billion per year.

In Guinea, deaths related to HIV and tuberculosis (TB) have increased in recent years. In a challenging environment where efforts need to be strengthened, grants signed by the Global Fund decreased between the 2015-17 and 2017-19 periods. In Myanmar, which has one of the highest HIV prevalence rates in the Asia-Pacific region, the projected funding gap for HIV/AIDS in the country is estimated at US$150 million.

The lack of funds available has an immediate impact on patients, as it can lead to gaps in drugs, diagnosis, prevention and care services. As MSF teams are observing in several projects, many people are not starting treatment on time or are forced to abandon treatment altogether, sometimes due to lack of drugs. Such a situation contributes to increased transmission, higher mortality, more treatment failures and an even higher prevalence of drug resistance – further increasing the cost of care for HIV and TB.

“At the beginning of my treatment, things weren’t going well, as there were constant stockouts [of drugs] and my health didn’t improve”, says Odia, an HIV-positive patient from Guinea. “I was recommended to MSF’s clinic in Conakry where this wouldn’t happen. Elsewhere, patients just die. A friend's husband comes here for treatment from Kankan, more than 600 km away, because there is nothing there.”

An urgent reality check is needed

Based on studies in nine countries where MSF runs HIV and TB programmes – Central African Republic, Democratic Republic of Congo, Eswatini, Guinea, Kenya, Malawi, Myanmar and Zimbabwe – the report shows that many countries facing a lack of external HIV/TB support are not yet ready to take over financing for HIV/TB care in the short term. Even though the political will exists, this would lead to gaps in the HIV/TB response. This is especially the case for countries affected by conflict or socio-economic crises.

"Sharing the burden of funding with countries affected by HIV and TB is in principle positive, as it can increase country ownership and independence from donor volatility," continues Dr Philips. "But this approach should be adapted to the reality in each country. When projections of a country’s capacity to raise domestic resources turn out to be over-optimistic, this puts both health programmes and people’s lives at risk.”

Ahead of the Global Fund replenishment conference, the MSF report calls on donor countries to take immediate action to reverse the decline in HIV and TB funding, starting by making strong commitments to Global Fund, and for donors to adapt their approach to the particular challenges their partner countries are facing.

"Failing to fix this will undermine past achievements and may lead to an epidemic rebound that will cost many lives,” says Dr Philips. “Donor countries must prevent the response from veering further off track."