Donor Government Funding for HIV in Low- and Middle-Income Countries in 2023

Introduction

This report provides the latest data on donor government resources available to address HIV in low- and middle-income countries, reporting on disbursements made in 2023. It is part of a collaborative tracking effort between UNAIDS and KFF that began almost 20 years ago, just as new global initiatives were being launched to address the epidemic. The analysis includes data from all 32 members of the Organisation for Economic Co-operation and Development (OECD)’s Development Assistance Committee (DAC), as well as non-DAC members who report data to the DAC. Data are collected directly from donor governments, UNAIDS, the Global Fund, and UNITAID, and supplemented with data from the DAC. Of the 32 DAC members, 14 provide 98% of total disbursements for HIV; data for these donors are presented individually. For the remaining 18 DAC members, data are provided in aggregate. All totals are presented in current U.S. dollars (amounts are not adjusted for inflation). While totals include both bilateral and multilateral assistance for the entire period (2002-2023), detailed disaggregated bilateral and multilateral amounts for all donors are only available starting in 2011 (see Methodology for more detail).

Findings

Total Funding

In 2023, donor government funding for HIV through bilateral and multilateral channels totaled US$7.86 billion in current USD (not adjusted for inflation) and accounted for approximately 37% of the US$22.1 billion estimated by UNAIDS to be available to address HIV (the total estimated resources is US$19.8 billion when measured in 2019 constant USD).^1,2,3,4 As per UNAIDS estimates, domestic resources accounted for 59%, and the remainder (4%) was from foundations, other multilateral organizations, and UN agencies. This amount is well below the US$29.3 billion that UNAIDS estimates will be needed by 2025 in order to reach global goals, and UNAIDS reports a widening funding gap overall and significant unmet need in funding for HIV prevention.⁵

Donor government funding for HIV in 2023 declined by US$358 million compared to 2022 (US$7.86 in 2023 compared to $8.22 billion in 2022) (See Figure 1 and Table 1).⁶ While there were actual declines in bilateral funding by several donor governments, the overall decrease was largely due to the timing of donor contributions to the Global Fund.

Looking more broadly, HIV funding in 2023 was essentially the same as in 2008 (US$7.78 billion), and well below the peak level reached in 2014 (US$8.60 billion). While funding has fluctuated since 2008, overall amounts have not kept up with inflation.

The U.S. continued to be the largest donor to HIV efforts, providing US$5.71 billion and accounting for 73% of total donor government funding in 2023. The second largest donor was the U.K. (US$714 million, 9%), followed by France (US$320 million, 4%), Germany (US$228 million, 3%), and the Netherlands (US$187 million, 2%). In 2023, 91% of total donor government funding for HIV was provided by these five donors.

While most funding from donors was provided bilaterally (71%), largely driven by the U.S. (which provided 92% of its funding through bilateral channels), the majority of donors (ten – Canada, European Commission, France, Germany, Ireland, Italy, Japan, Norway, Sweden, and the U.K.) provide a larger share of their resources through multilateral channels (See Figure 2). Since 2011, most donor governments, other than the U.S., have shifted away from bilateral support. In 2011, 54% of their HIV funding was provided through bilateral channels compared to only 16% in 2023 (see below for more on bilateral disbursements and multilateral contributions).

Bilateral Disbursements

Bilateral disbursements for HIV from donor governments – that is, funding disbursed by a donor on behalf of a recipient country or region – totaled US$5.58 billion in 2023, a decrease of US$46 million compared to 2022 (US$5.62 billion). This decline was due to decreased bilateral funding from half of the donor governments; all other donor governments either increased bilateral support or remained flat (See Figure 3). These trends were the same after accounting for exchange rate fluctuations.

Bilateral disbursements by the U.S. declined slightly, by US$41 million (-1%) in 2023 (US$5.23 billion) compared to 2022 (US$5.28 billion) (See Figure 4) and represented the largest bilateral decrease (in USD) among donor governments. However, the change was due to the timing of disbursements of prior year funding and was not an actual decrease in funding commitments from the U.S. In fact, bilateral HIV funding as specified by the U.S. Congress in annual appropriations has been flat for several years.⁷ When the U.S. decrease is removed, bilateral funding from all other donor governments declined by US$5 million in 2023 (US$343 million) compared to 2022 (US$348 million).

Since 2011, bilateral funding from donor governments, other than the U.S., has decreased by approximately US$1.37 billion (80%) (See Figure 5). As a result, the U.S. has accounted for an increasing share of bilateral resources, rising from 70% in 2011 to 94% in 2023, with fluctuations in U.S. disbursements having an outsized impact on overall bilateral trends.

Multilateral Contributions

Multilateral contributions from donor governments to the Global Fund, UNITAID, and UNAIDS for HIV – funding disbursed by donor governments to these organizations which in turn use some (Global Fund and UNITAID) or all (UNAIDS) of that funding for HIV – totaled US$2.28 billion in 2023 (after adjusting for an HIV share to account for the fact that the Global Fund and UNITAID address other diseases).⁸ Funding was US$2.07 billion for the Global Fund, US$56 million for UNITAID, and US$151 million for UNAIDS.

The decline in donor government multilateral funding in 2023 was largely due to the timing of contributions to the Global Fund, reflecting pledge periods, and not actual decreases in support. With 2023 marking the first year of the most recent pledge period (2023-2025), there were large fluctuations in contributions to the Global Fund from most donor governments when compared to 2022 totals. Some donors choose to “front-load” contributions (e.g., the U.K. fulfilled almost its entire pledge for 2023-2025 in 2023), while others choose to fulfill pledges towards the end of the pledge period (e.g., Denmark did not provide any contribution in 2023 and will likely be fulfilling its pledge in future years). In addition, the timing of U.S. contributions to the Global Fund is based on the amount of funding received from other donors, as the U.S. is required by law not to exceed 33% of total contributions to the Global Fund from all donors, which also results in significant year-to-year fluctuations (See Figure 6). More generally, donor governments have increased contributions to the Global Fund.

Fair Share

There are different ways to measure donor government contributions to HIV, relative to one another. While the U.S. government provides the largest amount of funding for HIV, for example, it also has one of the largest economies in the world. To assess relative contributions, or “fair share”, two measures were used: ranking by overall funding amount and ranking by funding for HIV per US$1 million GDP, to adjust for the size of donor economies (See Table 2):

• Rank by share of total donor government funding for HIV: By this measure, the U.S. ranked first in 2023, followed the U.K., France, Germany, and the Netherlands. The U.S. has ranked #1 in absolute funding amounts since tracking efforts began.
• Rank by funding for HIV per US$1 million GDP: By this measure, the U.K. ranks first, followed by the U.S., the Netherlands, Sweden, and France (See Figure 7).⁹

Looking Forward

Donor government funding for HIV in low and middle-income countries will continue to be an important part of the sustainability of the HIV response for years to come, particularly given the funding gap for HIV prevention efforts. Yet future donor government funding levels seem uncertain at best, and while there has been significant progress in addressing the HIV epidemic –1.3 million people were newly infected with HIV in 2023, down from 2.1 million in 2010 – new infections are on the rise in some regions, including two (Eastern Europe and Central Asia and the Middle East and North Africa) that UNAIDS reports have the largest funding gaps and are making the least progress against their HIV epidemics.¹⁰ There are significant headwinds on the horizon that complicate the funding picture from donor governments. These include multiple geopolitical challenges, such as costs associated with ongoing conflicts and displacement of refugees, as well as broader economic forces, including continued inflationary pressures. In addition, there is a crowded global health replenishment schedule in the year ahead, with several global health institutions, including the Global Fund, seeking to raise funds from the same donors. Finally, national elections have recently concluded (European Union, France, and the U.K.) or will occur in the coming months (U.S.), the outcomes of which could shape future funding for HIV in 2024 and beyond.