Potential for additional government spending on HIV/AIDS in 137 low-income and middle-income countries: an economic modelling study

BACKGROUND: Between 2012 and 2016, development assistance for HIV/AIDS decreased by 20·0%; domestic financing is therefore critical to sustaining the response to HIV/AIDS. To understand whether domestic resources could fill the financing gaps created by declines in development assistance, we aimed to track spending on HIV/AIDS and estimated the potential for governments to devote additional domestic funds to HIV/AIDS. METHODS: We extracted 8589 datapoints reporting spending on HIV/AIDS. We used spatiotemporal Gaussian process regression to estimate a complete time series of spending by domestic sources (government, prepaid private, and out-of-pocket) and spending category (prevention, and care and treatment) from 2000 to 2016 for 137 low-income and middle-income countries (LMICs). Development assistance data for HIV/AIDS were from Financing Global Health 2018, and HIV/AIDS prevalence, incidence, and mortality were from the Global Burden of Disease study 2017. We used stochastic frontier analysis to estimate potential additional government spending on HIV/AIDS, which was conditional on the current government health budget and other finance, economic, and contextual factors associated with HIV/AIDS spending. All spending estimates were reported in 2018 US$. FINDINGS: Between 2000 and 2016, total spending on HIV/AIDS in LMICs increased from $4·0 billion (95% uncertainty interval 2·9–6·0) to $19·9 billion (15·8–26·3), spending on HIV/AIDS prevention increased from $596 million (258 million to 1·3 billion) to $3·0 billion (1·5–5·8), and spending on HIV/AIDS care and treatment increased from $1·1 billion (458·1 million to 2·2 billion) to $7·2 billion (4·3–11·8). Over this time period, the share of resources sourced from development assistance increased from 33·2% (21·3–45·0) to 46·0% (34·2–57·0). Care and treatment spending per year on antiretroviral therapy varied across countries, with an IQR of $284–2915. An additional $12·1 billion (8·4–17·5) globally could be mobilised by governments of LMICs to finance the response to HIV/AIDS. Most of these potential resources are concentrated in ten middle-income countries (Argentina, China, Colombia, India, Indonesia, Mexico, Nigeria, Russia, South Africa, and Vietnam). INTERPRETATION: Some governments could mobilise more domestic resources to fight HIV/AIDS, which could free up additional development assistance for many countries without this ability, including many low-income, high-prevalence countries. However, a large gap exists between available financing and the funding needed to achieve global HIV/AIDS goals, and sustained and coordinated effort across international and domestic development partners is required to end AIDS by 2030. FUNDING: The Bill & Melinda Gates Foundation.