Long-term financing needs for HIV control in sub-Saharan Africa in 2015-2050: a modelling study

Abstract

Objectives: To estimate the present value of current and future funding needed for HIV treatment and prevention in 9 sub-Saharan African (SSA) countries that account for 70% of HIV burden in Africa under different scenarios of intervention scale-up. To analyse the gaps between current expenditures and funding obligation, and discuss the policy implications of future financing needs.

Design: We used the Goals module from Spectrum, and applied the most up-to-date cost and coverage data to provide a range of estimates for future financing obligations. The four different scale-up scenarios vary by treatment initiation threshold and service coverage level. We compared the model projections to current domestic and international financial sources available in selected SSA countries.

Results: In the 9 SSA countries, the estimated resources required for HIV prevention and treatment in 2015-2050 range from US$98 billion to maintain current coverage levels for treatment and prevention with eligibility for treatment initiation at CD4 count of <500/mm(3) to US$261 billion if treatment were to be extended to all HIV-positive individuals and prevention scaled up. With the addition of new funding obligations for HIV--which arise implicitly through commitment to achieve higher than current treatment coverage levels--overall financial obligations (sum of debt levels and the present value of the stock of future HIV funding obligations) would rise substantially.

Conclusions: Investing upfront in scale-up of HIV services to achieve high coverage levels will reduce HIV incidence, prevention and future treatment expenditures by realising long-term preventive effects of ART to reduce HIV transmission. Future obligations are too substantial for most SSA countries to be met from domestic sources alone. New sources of funding, in addition to domestic sources, include innovative financing. Debt sustainability for sustained HIV response is an urgent imperative for affected countries and donors.

Keywords: PUBLIC HEALTH.

Figure 1

Annual resources required by nine sub-Saharan countries (US$ billions) from 2015 to 2050 (3% discounting).

Figure 2

Cumulative resources required by nine sub-Saharan countries (US$ billions) in between 2015–2035 and 2015–2050 (the numbers show projections with 3% discounting; the error bars show result for 0% and 5%) by different scenarios of service coverage. Note: Bars represent estimates using 3% discounting. Lower and upper bounds of lines represent estimates using 0% and 5% discounting, respectively.

Figure 3

Distribution and trend of treatment, prevention and structural costs for nine sub-Saharan countries in 2015–2050 for the four scenarios of treatment initiation and intervention scale up, with 3% discounting 500 current: scenario 1—treatment initiation at CD4 count of <500/mm³ and current coverage levels maintained All current: scenario 2—treatment initiation for all HIV positives and current coverage levels maintained 500 scale up scenario 3—universal coverage with eligibility for treatment initiation at CD4 count of <500/mm³ All scale-up: scenario 4—universal coverage with eligibility for treatment initiation for all HIV positives. Blue: treatment costs, orange: prevention costs, green: structural costs.

Figure 4

Per capita annual resources required by nine sub-Saharan countries ($US) from 2015 to 2050 (3% discounting).

Figure 5

Total expenditures on HIV from domestic and international sources combined (current US$) in selected sub-Saharan African countries, compared with estimated resource needs for treatment, prevention and structural interventions in 2015 under different coverage levels and eligibility for treatment. EAE, external AIDS expenditure; GEA, Government Expenditure on AIDS; RNE, resource needs estimate. GEA and EAE estimates are from Resch et al 2015.

Figure 6

Public debt, HIV obligations and Public and HIV debt-to-GDP ratios. Data sources: Current Total Debt for each country derived from the International Monetary Fund Debt Sustainability Analysis—Country Report.