The HIV Treatment Gap: Estimates of the Financial Resources Needed versus Available for Scale-Up of Antiretroviral Therapy in 97 Countries from 2015 to 2020

Abstract

Background: The World Health Organization (WHO) released revised guidelines in 2015 recommending that all people living with HIV, regardless of CD4 count, initiate antiretroviral therapy (ART) upon diagnosis. However, few studies have projected the global resources needed for rapid scale-up of ART. Under the Health Policy Project, we conducted modeling analyses for 97 countries to estimate eligibility for and numbers on ART from 2015 to 2020, along with the facility-level financial resources required. We compared the estimated financial requirements to estimated funding available.

Methods and findings: Current coverage levels and future need for treatment were based on country-specific epidemiological and demographic data. Simulated annual numbers of individuals on treatment were derived from three scenarios: (1) continuation of countries' current policies of eligibility for ART, (2) universal adoption of aspects of the WHO 2013 eligibility guidelines, and (3) expanded eligibility as per the WHO 2015 guidelines and meeting the Joint United Nations Programme on HIV/AIDS "90-90-90" ART targets. We modeled uncertainty in the annual resource requirements for antiretroviral drugs, laboratory tests, and facility-level personnel and overhead. We estimate that 25.7 (95% CI 25.5, 26.0) million adults and 1.57 (95% CI 1.55, 1.60) million children could receive ART by 2020 if countries maintain current eligibility plans and increase coverage based on historical rates, which may be ambitious. If countries uniformly adopt aspects of the WHO 2013 guidelines, 26.5 (95% CI 26.0 27.0) million adults and 1.53 (95% CI 1.52, 1.55) million children could be on ART by 2020. Under the 90-90-90 scenario, 30.4 (95% CI 30.1, 30.7) million adults and 1.68 (95% CI 1.63, 1.73) million children could receive treatment by 2020. The facility-level financial resources needed for scaling up ART in these countries from 2015 to 2020 are estimated to be US$45.8 (95% CI 45.4, 46.2) billion under the current scenario, US$48.7 (95% CI 47.8, 49.6) billion under the WHO 2013 scenario, and US$52.5 (95% CI 51.4, 53.6) billion under the 90-90-90 scenario. After projecting recent external and domestic funding trends, the estimated 6-y financing gap ranges from US$19.8 billion to US$25.0 billion, depending on the costing scenario and the U.S. President's Emergency Plan for AIDS Relief contribution level, with the gap for ART commodities alone ranging from US$14.0 to US$16.8 billion. The study is limited by excluding above-facility and other costs essential to ART service delivery and by the availability and quality of country- and region-specific data.

Conclusions: The projected number of people receiving ART across three scenarios suggests that countries are unlikely to meet the 90-90-90 treatment target (81% of people living with HIV on ART by 2020) unless they adopt a test-and-offer approach and increase ART coverage. Our results suggest that future resource needs for ART scale-up are smaller than stated elsewhere but still significantly threaten the sustainability of the global HIV response without additional resource mobilization from domestic or innovative financing sources or efficiency gains. As the world moves towards adopting the WHO 2015 guidelines, advances in technology, including the introduction of lower-cost, highly effective antiretroviral regimens, whose value are assessed here, may prove to be "game changers" that allow more people to be on ART with the resources available.

Fig 1. Baseline adult coverage by country under current eligibility scenario.

Bubble size represents the number of adults in need of ART in 2013, according to current country eligibility guidelines. The vertical axis shows the percentage of adults eligible for ART who received ART in 2013, which is the baseline coverage rate. The horizontal axis sorts the countries into six regions: Eastern and Southern Africa (AES), Asia and the Pacific (AP), Western and Central Africa (AWC), Eastern Europe and Central Asia (EECA), Latin America and the Caribbean (LAC), and the Middle East and North Africa (MENA). Not all countries included in the analysis are labeled in the figure.

Fig 2. Baseline pediatric coverage by country under current eligibility scenario.

Bubble size represents the number of children in need of ART in 2013, according to current country eligibility guidelines. The vertical axis shows the percentage of children eligible for ART who received ART in 2013, which is the baseline coverage rate. The horizontal axis sorts the countries into six regions: Eastern and Southern Africa (AES), Asia and the Pacific (AP), Western and Central Africa (AWC), Eastern Europe and Central Asia (EECA), Latin America and the Caribbean (LAC), and the Middle East and North Africa (MENA). Not all countries included in the analysis are labeled in the figure.

Fig 3. Antiretroviral regimens used in cost calculations.

This figure shows the regimens used to calculate the average cost of treatment in each country, along with the percentage of patients on each regimen in 2015 and 2020 among adult and pediatric patients on first- and second-line ART. Regimen distributions for 2016 to 2019 were estimated but are omitted from this figure. Please note: fixed-dose regimens are in square brackets. 3TC, lamivudine; ABC, abacavir; d4T, stavudine; EFV, efavirenz; FTC, emtricitabine; LPV/r, lopinavir/ritonavir; NVP, nevirapine; TDF, tenofovir; ZDV, zidovudine.

Fig 4. Estimating the funding gap.

We separately calculated the funding gap for ARVs and laboratory commodities versus that for facility-level overhead and personnel. For each country, we considered Global Fund contributions to commodity procurement, as well as PEPFAR and DCs to commodity procurement and overhead and personnel, as applicable. DCs were estimated using Global Fund CFTs in eligible countries or country-reported proportional contributions to the HIV response.

Fig 5. Estimated range of adults living with HIV on ART.

The vertical axis shows the number of adults, in millions, who are estimated to be on ART each year, while the horizontal axis shows years. Each color represents a different scenario, and the whiskers on each bar represent the lower and upper bound of the 95% confidence interval.

Fig 6. Estimated range of children living with HIV on ART.

The vertical axis shows the number of children, in thousands, who are estimated to be on ART each year, while the horizontal axis shows years. Each color represents a different scenario, and the whiskers on each bar represent the lower and upper bound of the 95% confidence interval.

Fig 7. Total adult resource needs for HIV treatment by scenario.

The vertical axis shows the cost of HIV treatment in millions of US dollars, and the horizontal axis shows the three scenarios. The whiskers show the upper and lower bounds of the 95% confidence interval.

Fig 8. Total pediatric resource needs for HIV treatment by scenario.

The vertical axis shows the cost of HIV treatment in millions of US dollars, and the horizontal axis shows the three scenarios. The whiskers show the upper and lower bounds of the 95% confidence interval.

Fig 9. Total adult ART resource requirements by region.

The graph shows percent of total adult ART resource requirements by region based on the current eligibility scenario. The vertical axis shows the cost of HIV treatment in billions of US dollars, and the horizontal axis shows the years of analysis. Labeled values do not equal 100% as only selected percentages are shown. AES, Eastern and Southern Africa; AP, Asia and the Pacific; AWC, Western and Central Africa; EECA, Eastern Europe and Central Asia; LAC, Latin America and the Caribbean; MENA, Middle East and North Africa.

Fig 10. Total pediatric ART resource requirements by region.

The graph shows percent of total pediatric ART resource requirements by region based on the current eligibility scenario. The vertical axis shows the cost of HIV treatment in billions of US dollars, and the horizontal axis shows the years of analysis. Labeled values do not equal 100% as only selected percentages are shown. AES, Eastern and Southern Africa; AP, Asia and the Pacific; AWC, Western and Central Africa; EECA, Eastern Europe and Central Asia; LAC, Latin America and the Caribbean; MENA, Middle East and North Africa.

Fig 11. Estimated financial resources available for ART.

This chart shows the total estimated financial resources available for ART by region, disaggregated by source, under the current eligibility scenario, assuming lower PEPFAR contributions to facility-level costs. The width of each region is proportional to the total volume of resources available. The MENA region has a narrow column because there are significantly fewer resources available for HIV in MENA than in the other regions in our analysis. AES, Eastern and Southern Africa; AP, Asia and the Pacific; AWC, Western and Central Africa; EECA, Eastern Europe and Central Asia; LAC, Latin America and the Caribbean; MENA, Middle East and North Africa.

Fig 12. Funding gap for HIV treatment.

This map shows the percentage of total costs under the current eligibility scenario—assuming conservative PEPFAR contributions—that remains unfunded after incorporating Global Fund, PEPFAR, and domestic contributions to ART. Countries' funding gaps are larger under the WHO 2013 and 90-90-90 scenarios.