Botswana offers publicly financed HIV treatment to citizens, but not migrants, who comprised about 7% of the population in 2016. However, HIV incidence is not declining in proportion to Botswana's ...HIV response. In 2018, Botswana had 86% of citizens living with HIV diagnosed, 95% of people diagnosed on treatment, and 95% viral suppression among those on treatment. We hypothesised that continued exclusion of migrants is hampering reduction of HIV incidence in Botswana. Hence, we modelled the impact of including migrants in Botswana's HIV response on achieving 90-90-90 and 95-95-95 Fast-Track targets by 2020 and 2030, respectively.
The Optima HIV model, with demographic, epidemiological, and behavioural inputs, was applied to citizens of and migrants to Botswana. Projections of new HIV infections and HIV-related deaths were compared for three scenarios to the end of 2030: (1) continued status quo for HIV testing and treatment coverage, and maintenance of levels of linkage to care, loss to follow-up, and viral suppression among citizens and migrants (baseline); (2) with scaled-up budget, optimised to achieve 90-90-90 and 95-95-95 Fast-Track targets by 2020 and 2030, respectively, for citizens only; and (3) scaled-up optimised budget to achieve these targets for both citizens and migrants.
A baseline of 172,000 new HIV infections and 8,400 HIV-related deaths was projected over 2020-2030. Scaling up to achieve targets among citizens only averted an estimated 48,000 infections and 1,700 deaths. Achieving targets for both citizens and migrants averted 16,000 (34%) more infections and 442 (26%) more deaths. Scaling up for both populations reduced numbers of new HIV infections and deaths by 44% and 39% respectively compared with 2010 levels. Treating migrants when scaling up in both populations was estimated to cost USD 74 million over 2020-2030.
Providing HIV services to migrants in Botswana could lead to further reductions in HIV incidence and deaths. However, even with an increased, optimised budget that achieves 95-95-95 targets for both citizens and migrants by 2030, the 90% incidence reduction target for 2020 will be missed. Further efficiencies and innovations will be needed to meet HIV targets in Botswana.
ObjectivesAssess the relationship between income inequality and HIV incidence, AIDS mortality and COVID-19 mortality.DesignMulticountry observational study.Setting217 countries for HIV/AIDS analysis, ...151 countries for COVID-19 analysis.ParticipantsUsed three samples of national-level data: a sample of all countries with available data (global sample), a subsample of African countries (African sample) and a subsample excluding African countries (excluding African sample).Main outcome measuresHIV incidence rate per 1000 people, AIDS mortality rate per 100 000 people and COVID-19 excess mortality rate per 100 000 people. The Gini index of income inequality was the primary explanatory variable.ResultsA positive and significant relationship exists between the Gini index of income inequality and HIV incidence across all three samples (p<0.01), with the effect of income inequality on HIV incidence being higher in the African sample than in the rest of the world. Also, a statistically positive association exists for all samples between income inequality and the AIDS mortality rate, as higher income inequality increases AIDS mortality (p<0.01). For COVID-19 excess mortality rate, a positive and statistically significant relationship exists with the Gini index for the entire sample and the excluding African sample (p<0.05), but the African sample alone did not deliver significant results (p<0.1).ConclusionCOVID-19 excess deaths, HIV incidence and AIDS mortality are significantly associated with income inequality globally—more unequal countries have a higher HIV incidence, AIDS mortality and COVID-19 excess deaths than their more equal counterparts. Income inequality undercuts effective pandemic response. There is an urgent need for concerted efforts to tackle income inequality and to build pandemic preparedness and responses that are adapted and responsive to highly unequal societies, prioritising income inequality among other social determinants of health.
HIV/AIDS remains a leading global cause of disease burden, especially in low- and middle-income countries (LMICs). In 2020, more than 80% of all people living with HIV (PLHIV) lived in LMICs. While ...progress has been made in extending coverage of HIV/AIDS services, only 66% of all PLHIV were virally suppressed at the end of 2020. In addition to more resources, the efficiency of spending is key to accelerating progress towards global 2030 targets for HIV/AIDs, including viral load suppression. This study aims to estimate the efficiency of HIV/AIDS spending across 78 countries. We employed a data envelopment analysis (DEA) and a truncated regression to estimate the technical efficiency of 78 countries, mostly low- and middle-income, in delivering HIV/AIDS services from 2010 to 2018. Publicly available data informed the model. We considered national HIV/AIDS spending as the DEA input, and prevention of mother to child transmission (PMTCT) and antiretroviral treatment (ART) as outputs. The model was adjusted by independent variables to account for country characteristics and investigate associations with technical efficiency. On average, there has been substantial improvement in technical efficiency over time. Spending was converted into outputs almost twice as efficiently in 2018 (81.8%; 95% CI = 77.64, 85.99) compared with 2010 (47.5%; 95% CI = 43.4, 51.6). Average technical efficiency was 66.9% between 2010 and 2018, in other words 33.1% more outputs could have been produced relative to existing levels for the same amount of spending. There is also some variation between WHO/UNAIDS regions. European and Eastern and Southern Africa regions converted spending into outputs most efficiently between 2010 and 2018. Rule of Law, Gross National Income, Human Development Index, HIV prevalence and out-of-pocket expenditures were all significantly associated with efficiency scores. The technical efficiency of HIV investments has improved over time. However, there remains scope to substantially increase HIV/AIDS spending efficiency and improve progress towards 2030 global targets for HIV/AIDS. Given that many of the most efficient countries did not meet 2020 global HIV targets, our study supports the WHO call for additional investment in HIV/AIDS prevention and control to meet the 2030 HIV/AIDS and eradication of the AIDS epidemic.
Understanding barriers to access to essential health services is critical for devising effective strategies to improve access and align such strategies with national health and development policy ...objectives. However, while considerable empirical evidence exists on correlates of HIV prevalence and populations at risk of contracting HIV, there is very little such evidence on access to antiretroviral therapy. This paper addresses this gap through a cross-sectional analysis of coverage of antiretroviral therapy and its correlates across 47 counties in Kenya. It considers health-sector and social factors, and applying instrumental variables to address error-in-variables and reverse-causality issues regarding HIV prevalence. Poverty was the most robust and - statistically and substantially - significant determinant of treatment coverage. The gap in treatment coverage between the poorest and richest counties amounted to about 40 percentage points and has not narrowed between 2012 and 2015. Health sector capacities independently played a role and exacerbated the poverty gap. For Kenya, the results suggest that policies on expanding treatment access need to be differentiated across counties to greatest effect and to align the HIV/AIDS response with national health and social policy objectives. Regarding global HIV/AIDS policies, the findings suggest a need to recognise "people left behind" owing to socio-economic and specifically poverty-related barriers to access to services.
The role of trust funds in the practice of and the policy discourse on the sustainable financing for health and HIV is growing. However, there is a paucity of political analyses on implementing trust ...fund arrangements. Drawing on a novel meta-framework - connecting multiple streams and advocacy coalition frameworks to policy cycle models of analysis - to politically analyse HIV financing policy design, adoption and implementation as well as insights from public finance literature, this article critically analyses the politics of the AIDS Trust Fund (ATF) in Uganda. We find that politics was the most fundamental driver for the establishment of the ATF. Whereas HIV financing is inherently both technical and political, enacting the ATF was largely a geopolitical positioning policy instrument that entailed navigating political economy challenges in managing multiple stakeholder groups' politics. With the mandated tax revenues earmarked to capitalise the ATF covering only 0.5% of the annual resource needs, we find a very insignificant potential to contribute to financial sustainability of the national HIV response per se. As good ideas and evidence alone often do not necessarily produce desired results, we conclude that systematic and continuous political analysis can bring meaningful insights to our understanding of political economy dimensions of the ATF as an innovative financing policy instrument, thereby helping drive technically sound health financing policy proposals into practice more effectively. For Uganda, while proponents have invested a considerable amount of hope in the ATF as a source of sustainable domestic funding for the HIV response, substantial work remains to be done to address a number of questions that continue to beguile the current ATF architecture. Regarding global health financing policy, the findings suggest the need to pay attention to the position, power and interests of stakeholders as a powerful lever in health financing policy reforms.
History matters: AIDS in the time of COVID-19 Birungi, Charles; Parker, Warren; Whiteside, Alan
African journal of AIDS research : AJAR,
04/2022, Letnik:
21, Številka:
2
Journal Article
This article assesses the impact of the HIV and COVID-19 pandemics and debt dynamics on health, HIV and pandemic preparedness and response-related financing in developing countries. Using a novel ...dataset, we did a cross-national systematic analysis of all data sources available for government expenditures on health, HIV, COVID-19 and debt servicing in selected developing countries. We found an inadequate multilateral response with the ensuing gaps allowing both pandemics to thrive. The G20 Debt Service Suspension Initiative and the Common Framework only covered countries with a third of the global population of people living with HIV. Rising and unsustainable debt levels are limiting the capacity of governments to protect the health of their populations. Government spending is already falling in response to high debt payments. Specifically, debt servicing is crowding out lifesaving investments. In 2020, for every USD 5 available, USD 4 was spent on debt servicing. Only USD 1 was invested in health. This is a binding constraint on countries' efforts to control COVID-19. Even with a gargantuan effort to increase health expenditure, the outlook for health financing remains negative. Fiscal consolidation, with a heavy emphasis on expenditure cuts, is expected to take place across 139 countries in the coming years. These findings suggest that fiscal policymakers should be concerned about the crowding-out and constraining effects of public debt. To this end, pragmatic recommendations are made to treat and cancel debt as a critical policy lever to accelerate the end of the HIV and COVID-19 pandemics in developing countries as a key condition to addressing the growing inequalities and to ensure debt can be a benefit, not a burden.
This Ph.D. aims to propose a pragmatic approach to the long-term fiscal sustainability of the HIV and HIV response in Uganda. It is motivated by the fact that whereas financing of the HIV response ...has been among the dominant economic development issues over the last years, it now faces an uncertain outlook. Using a mixed-methods research approach, this Ph.D.'s empirical, theoretical, and methodological contributions improve our understanding of the economics (and politics) of achieving fiscal sustainability of HIV responses. Empirically, I found that Uganda will not "end AIDS" by 2030 despite projected significant reductions in AIDS deaths and new HIV infections by 68% and 80% respectively between 2010 and 2030 under a scale-up strategy, the Fast-Track approach. From a fiscal perspective, the corresponding direct and indirect HIV-induced contingent fiscal liabilities range between 150% and 200% of GDP (in 2015 terms). To cope with these fiscal quasi-liabilities implied by the national HIV response, a novel analytical framework for achieving fiscal sustainability of HIV responses is proposed and, through a proof-of-concept, validated in this Ph.D. Theoretically informed and relying on a set of core principles, behavioral economics-inspired, explicit political analysis and, game-theoretic approaches, I empirically assess the likely evolution of future public spending and revenues through analytic policy simulations and conclude that the fiscal space created from applying this novel and pragmatic approach could meet the above-mentioned HIV-induced contingent fiscal liabilities estimated at US$ 24 billion by 2030. This Ph.D. also explores political economy considerations regarding long-term funding for the HIV response. This Ph.D. hopes to contribute to technically sound and politically achievable approaches to addressing HIV-related long-term fiscal challenges in Uganda and, more broadly, toward literature on the political economy of fiscal sustainability.
Understanding the economic implications of COVID-19 for the HIV epidemic and response is critical for designing policies and strategies to effectively sustain past gains and accelerate progress to ...end these colliding pandemics. While considerable cross-national empirical evidence exists at the global level, there is a paucity of such deep-dive evidence at national level. This article addresses this gap. While Zimbabwe experienced fewer COVID-19 cases and deaths than most countries, the pandemic has had profound economic effects, reducing gross domestic product by nearly 7% in 2020. This exacerbates the long-term economic crisis that began in 1998. This has left many households vulnerable to the economic fallout from COVID-19, with the number of the extreme poor having increased to 49% of the population in 2020 (up from 38% in 2019). The national HIV response, largely financed externally, has been one of the few bright spots. Overall, macro-economic and social conditions heavily affected the capacity of Zimbabwe to respond to COVID-19. Few options were available for borrowing the needed sums of money. National outlays for COVID-19 mitigation and vaccination amounted to 2% of GDP, with one-third funded by external donors. Service delivery innovations helped sustain access to HIV treatment during national lockdowns. As a result of reduced access to HIV testing, the number of people initiating HIV treatment declined. In the short term, there are likely to be few immediate health care consequences of the slowdown in treatment initiation due to the country's already high level of HIV treatment coverage. However, a longer-lasting slowdown could impede national progress towards ending HIV and AIDS. The findings suggest a need to finance the global commons, specifically recognising that investing in health care is investing in economic recovery.
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