Global philanthropic funding increased by 4.1 percent from 2016 levels and amounted to US$164 million, or 14.6 percent of overall funding. The Bill and Melinda Gates Foundation (BMGF) remained the largest funder and increased its contribution by 6.6 percent, to US$150.2 million. Wellcome Trust investment fell for the fifth consecutive year to an annual US$2 million.
The full report, HIV Prevention Research & Development Investments 2017: Investing to end the epidemic, is available for download.
[UPDATE]: The new report was a feature story by UNAIDS, Global HIV prevention targets at risk.
Today, the Resource Tracking for HIV Prevention R&D Working Group (Working Group) launched its 14th annual report—which details 2017 investments—at the HIV Research for Prevention (HIVR4P) conference in Madrid.
Flat and/or reduced funding for HIV/AIDS and other global health issues threatens to roll back progress worldwide. There is belated and widespread acknowledgment of a prevention crisis that can only be addressed by taking today’s tools to scale while researching new ones. Given this backdrop, the report is a powerful advocacy tool. This year’s report notes troubling trends in investment flows for biomedical HIV prevention at a moment of major promise in the research landscape. The report tracks the origins, trends and direction of global funding as well as the resulting effect(s) on the prevention research funding landscape.
Key Findings
The report shows that funding for HIV prevention research funding declined for the fifth consecutive year—and by 3.5 percent in 2017 to US$1.13 billion—the lowest total observed since 2005. This reduction was unevenly distributed. Investment increased for pre-exposure prophylaxis (PrEP) and voluntary medical male circumcision (VMMC) but decreased for AIDS vaccines, microbicides, prevention of vertical transmission (PMTCT), treatment as prevention (TasP) and female condoms.
The overall decline is driven largely by a reduction in US public-sector funding, with levels dropping by 5.8 percent from 2016 to US$830 million. This is a five-year low in investment. Outside the US public sector, another major decrease came from the European Commission, with funding levels dropping by 47 percent to US$7.6 million in 2017. The impact of these cuts was cushioned by increases from Australia, Brazil, Canada, Japan and the Netherlands. While the number of philanthropic donors decreased from 12 to 10 in 2017, levels of funding grew by 4.1 percent to US$164 million or 14.6 percent of overall funding. This is largely due to the 6.6 percent increase in investment from the Bill & Melinda Gates Foundation.
The report notes that the HIV prevention R&D space is at an exciting yet precarious juncture. Ongoing late-stage efficacy trials for preventive AIDS vaccines, long-acting injectable PrEP and antibody-mediated prevention could yield new options in the coming years. Then there’s also the dapivirine vaginal ring that is currently awaiting a regulatory opinion from the European Medical Association. However, the current funding landscape is not set up for sustainability or longevity, which is essential to help ensure that new products move from research and eventually to those who need it. Out of every dollar spent on HIV prevention research, 87 cents are from the two biggest donors, the US public sector and the Gates Foundation—a literal case of having all the coins in one basket. The report advocates for diversifying the funding base and developing long-term funding strategies to support the delivery of innovative prevention tools and a durable end to the epidemic.
The Resource Tracking Working Group hopes these reports will serve as tools for advocacy and be used to inform public policy that supports and helps to accelerate scientific progress. We thank all of the individuals who contributed data to the report and who gave time and effort as trial participants.
Check out the report, share it with your fellow advocates, and be sure to let us know if your organization is a funder or recipient of HIV prevention grants, or if you have further questions!
We are kicking off the launch of the report with a press conference at HIV R4P, which can be viewed live at the conference Facebook page and will be archived on the conference website.
Press Release
AVAC: Kay Marshall, kay@avac.org, +1-347-249-6375
IAVI: Anita Kawatra, akawatra@iavi.org, +1 212-847-1055
Madrid – HIV prevention research funding continued to decline in 2017 for the fifth consecutive year, driven largely by a five-year low in US public sector funding, according to a report released today at the HIV Research for Prevention (HIVR4P 2018) conference in Madrid, Spain.
The Resource Tracking for HIV Prevention R&D Working Group’s 14th annual report, Investing to End the Epidemic, documents funding that fell to the lowest level in more than a decade: In 2017, funding for HIV prevention research and development (R&D) decreased by 3.5 percent (US$40 million) from the previous year, falling to US$1.13 billion.
This declining funding comes at a time of great optimism for research, with a slate of efficacy trials across the prevention pipeline – including major HIV vaccine, passive antibody and next generation PrEP efficacy trials – and critical follow-on research for proven antiretroviral-based prevention options, notably the dapivirine vaginal ring. But it also comes a time when the broader HIV field is grappling with a prevention crisis that is exacerbated by decreased funding for the overall HIV response and a lack of political will to adequately fund a response that will ensure the world meets the ambitious prevention targets to end the epidemic.
The Working Group warns that getting to zero new infections will not only require the expansion of existing options like voluntary medical male circumcision (VMMC) and oral pre-exposure prophylaxis (PrEP), but also the development of innovative new products, including long-acting, antiretroviral-based prevention options and a vaccine. Sustained funding is critical to keep the full gamut of HIV prevention research moving forward in a timely manner. Even small declines in funding can delay or sideline promising, new HIV prevention options that are needed to end the HIV epidemic.
“Make no mistake. We are in a prevention crisis and we cannot afford a further funding crisis,” said Mitchell Warren, AVAC executive director. “It is unacceptable that donor funding for HIV prevention research continues to fall year after year even as research is moving new options closer to reality. We need continued and sustained investment to keep HIV prevention research on track to provide the additional tools that are required for sustainable, durable control of the HIV epidemic.”
The US government continued to be the major funder of HIV prevention research, contributing almost three-fourths of overall funding. A decrease of almost six percent, though, brought funding to a five-year low of US$830 million. The Working Group noted that sharp declines in US government funding have a major impact on the biomedical HIV prevention R&D field. With uncertainty around continued political will to fund the HIV response, this trend is extremely worrying.
Together, the US public sector and the Bill & Melinda Gates Foundation (BMGF) represented 87 percent of the total global investment in 2017, an imbalance that has continued for several years. The Working Group in this year’s report cautioned against the disproportionate impact of shifting donor priorities by these two donors on cutting-edge research, noting that a US$50 million decrease in vaccine R&D in 2017 was largely attributed to cuts from the US government, while a 67 percent increase in VMMC funding in 2017 is due largely to enhanced investment from BMGF. The Working Group renewed a call to diversify the funding base to ensure both the sustainability of the field and that decades of gains made in scientific innovation are not lost to fluctuating investment.
The Working Group noted with concern that funding by the European Commission (EC) dropped by almost half from 2016 to 2017 (US$14.4 million in 2016 to US$7.6 million). Noting increases in public sector funding from Canada, Brazil and the Netherlands, the Working Group called on other European countries to increase investment in critical HIV prevention tools to help end the epidemic and to offset the drop in EC funding.
“A true end to AIDS will only be possible if we can develop and deploy an effective, accessible HIV vaccine and other biomedical innovations to prevent HIV infection,” said Mark Feinberg, M.D., Ph.D., President and CEO of the International AIDS Vaccine Initiative. “Decades of research are paying off with the most exciting advances we’ve seen to date. But progress can only continue with sustained public and private sector investment in HIV prevention R&D.”
As researchers, implementers, advocates and funders gather this week in Madrid to review progress in HIV prevention research, there is much to be optimistic about in HIV science and in the accumulated knowledge of how to end the epidemic. At the same time, sobering changes in the funding and policy environment could imperil future progress and wipe out the progress made. Funding constraints, policy changes, shifting donor priorities and shifting demographics will all play a role in the world’s ability to respond to the continued challenges that HIV presents.
“With 5000 people becoming infected with HIV every day it is critical that we both scale up the effective HIV prevention programmes we currently have and invest in new technologies and solutions so that they can become a reality for the populations most affected by HIV,” said Tim Martineau, Deputy Executive Director, Programme a.i. UNAIDS. “Doing both will avert new infections, save lives and reduce the rising costs of life-long antiretroviral treatment.”
The report and infographics on prevention research investment are online at www.hivresourcetracking.org and on social media with #HIVPxinvestment.
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Since 2000, the Resource Tracking for HIV Prevention R&D Working Group (formerly the HIV Vaccines & Microbicides Resource Tracking Working Group) has employed a comprehensive methodology to track trends in research and development (R&D) investments and expenditures for biomedical HIV prevention options. AVAC leads the secretariat of the Working Group, that also includes the International AIDS Vaccine Initiative (IAVI) and the Joint United Nations Programme on HIV/AIDS (UNAIDS). This year’s report is additionally made possible by the support of several donors, including the Bill & Melinda Gates Foundation and the American people through the US President’s Emergency Plan for AIDS Relief (PEPFAR) and the US Agency for International Development (USAID). The contents are the responsibility of AVAC and the Working Group and do not necessarily reflect the views of PEPFAR, USAID or the United States Government. AVAC does not accept funding from the pharmaceutical industry.
1.3 million person gap between the current rate and the 2020 target.
Across Treatment U=U and prevention programs, peer navigators, mentor mothers and lay counselors are recognized as essential to good services. Yet many countries don’t have clear schemas for quantifying the number of individuals needed, budgeting for their remuneration and defining the roles and responsibilities that lead to impact. Activists are working to ensure clarity by demanding from governments, funders and implementers.
Many countries report low initiation and continuation of PrEP. This doesn’t mean people don’t want the product. They might not want the program that’s offering it; or they might not be being reached. A “demand-creation cascade” such as the one proposed here for PrEP is one way to evaluate the program and the product. It would measure how many people received the full suite of demand-side activities the program hopes to deliver at a given stage. The precise set of steps would depend on the service-delivery design and strategy in question.
We need to give women the choice to use DTG or not and to use contraception if indicated and desired. We need to support choices across options, with risk reduction—not use of a specific product—as the primary outcome. We need to give women the choice to use DMPA-IM or –SC or not, and to use HIV prevention as desired.
Today AVAC released No Prevention, No End, our 2018 annual report on the state of the field. Starting from the title—which humbly borrows the cadence of the call for an end to state-sanctioned violence against Black Americans, “No Justice, No Peace”—through to the closing words, “This is the worst possible moment for slowing down,” the Report is a call to action and guide for addressing the HIV prevention crisis that threatens progress in curtailing epidemics worldwide.
Click here to download the Report and individual sections and graphics; click here for a new episode of the Px Pulse podcast which covers the Report’s key themes and features lead author Emily Bass, AVAC’s Director of Strategy and Content.
UNAIDS named the prevention crisis in its July 2018 report, Miles to Go. It acknowledged that the scale-up of antiretroviral treatment, while essential, is insufficient as a prevention strategy. AVAC has been warning of an imbalance in approaches and investments across approaches, and calling for ambitious targets matched with political will, financing, timelines and more since the UNAIDS targets were first launched in 2014. (Check out AVAC Report 2014/5: Prevention on the Line for a summary of this critique of targets.)
In this year’s Report, we call out three core problems with primary prevention and the global HIV response, identifying the risks they bring and the path to a solution. Specifically, we focus on:
AVAC is launching this Report as many stakeholders in HIV prevention research gather in Madrid for the HIV Research for Prevention (R4P) conference. Visit our special R4P page to find us on-site and follow along from afar, to see how the themes of this year’s Report resonate in a global and wide-ranging discussion of HIV prevention research and implementation at a critical time.
In the new issue of Px Wire, AVAC gives our take on this year’s PEPFAR process for establishing the Country Operational Plans (COPs). These plans define what work will be done with PEPFAR money at the country level and how that work will be evaluated in each of the 63 countries that receive PEPFAR money.
The process has changed considerably since last year, allowing for deeper insights into what’s working and what’s not. In this issue, AVAC takes you through the good and bad of PEPFAR’s emphasis on index testing, analyzes crucial gaps in combination prevention, and lays out a series of questions to shape a powerful agenda for advocacy.
This issue’s centerspread takes a closer look at Zimbabwe’s data, and highlights amfAR’s detailed country factsheets that draw from PEPFAR’s giant data sets. Additional tools and information on influencing the COPs process are available from COMPASS partner Health GAP’s PEPFAR Watch.
Find the full issue Px Wire and the archive of past issues at www.avac.org/pxwire.
Rob Newells is the newly appointed Executive Director of AIDS Project of the East Bay; he is minister and founder of the the HIV program at Imani Community Church in Oakland and is a PxROAR member since 2012.
The annual Conference on Retroviruses and Opportunistic Infections (CROI) brings together thousands of researchers from around the world to share the latest information on HIV, AIDS, and related infectious diseases. The 2018 meeting in Boston highlighted 114 oral abstracts and 991 posters in 23 different science categories, from Virology to Population and Cost Modeling.
The time lag from research to implementation in health can be long. One study from 2011 suggested an average 17-year delay (Morris, Wooding, and Grant, 2011). This graphic (adapted by AVAC from Dana Hovig at the Bill and Melinda Gates Foundation) shows a five year lag in the US for vaccines and drugs. As one of 26 Community Educator Scholarship Awardees at this year’s Conference on Retroviruses and Opportunistic Infections (CROI), it is my goal to help reduce that delay by focusing on research that has the potential to impact community members and frontline workers who I interact with on a daily basis in the short term.
I am sure that scientists and advocates will spend the next year talking to each other about the issues and information that came from oral abstract sessions reporting on long-acting cabotegravir (Abstract 83) and dapivirine ring studies (Abstract 143LB and Abstract 144LB). Advocates should also be engaging community members and frontline workers in conversations about these emerging tools for HIV prevention.
Almost six years after FDA approval, oral PrEP is a part of the HIV prevention landscape worldwide, but it looks different depending who you are and where you live. PrEP access still seems to be among the most relevant issues for HIV-negative black MSM in the United States, while viral suppression (which is key to improving health outcomes and eliminating the risk of onward transmission) remains a priority concern for PLHIV. Do PrEP and treatment as prevention really give us all of the tools we need to end the HIV epidemic? What follows are a few of my (US-centered, black MSM-focused) highlights from #CROI2018:
Does PrEP drive STI rates? No! Abstract 1025 looked at condom use patterns in about 300 MSM and transgender participants in a PrEP pilot study. Reported condom use did drop, but overall rates of STI diagnosis didn’t not rise. The investigators conclude that “neither overall condom use nor change in condom use were associated with STI diagnosis.” Good predictors of STI diagnosis among PrEP users included being under 25 years old, being diagnosed with an STI in the 6 months prior to starting PrEP, and the number of sex partners. The researchers conclude that “particular attention and support is needed for younger PrEP users,” and, “although many PrEP prevention messages stress condom use, the number of partners appears to be a more important predictor of STI diagnosis among PrEP users.”
…and, in an exploration of the intersection of PrEP and STIs in the United States, Dr. Julia Schillinger said, “as researchers are looking at retention on PrEP, maybe one of the things they could also measure is, even if people aren’t retained on PrEP, are they retained in a system of testing and primary care?”
Should PrEP be prescribed for people who use meth? Yes! Starting with data from the iPrEX study and its open-label extension, it’s been clear that people at risk of HIV and unable to use condoms will use PrEP correctly and consistently. A study of these issues at CROI found more evidence of this. The study enrolled MSM who were using PrEP and reported condomless anal sex with multiple partners (CAS-MP). Some also reported stimulant use. The researchers wanted to know how stimulant use and condomless anal sex affected adherence to PrEP. They measured the presence of PrEP in blood samples from the study participants. (This can give a more accurate picture of whether people are taking PrEP than their own reports. Overall, 80 percent of participants in the study had protective levels of PrEP in their blood over the course of the 48 week study, regardless of stimulant use or frequency of condomles anal sex.) Conclusion: “Stimulant use should not be a deterrent to prescribe PrEP to high-risk individuals engaging in CAS-MP.”
Short-term PrEP as part of vacation package??? Yes! Advocates have stressed for years that oral PrEP is not forever. Rather, it should be used during a person’s “season of risk.” Sometimes those seasons aren’t very clear. Sometimes they are. Researchers investigating the feasibility of short-term, fixed interval, episodic PrEP (epi-PrEP) found in a study of 54 men who have sex with men (MSM) that most were adherent during short, high risk vacation periods. Study participants started oral PrEP 7 days prior to vacation and were instructed to adhere to daily dosing through seven days post-vacation. (They also received a single session of cognitive behavioral therapy at least two weeks before the vacation.) Nearly 94 percent of the men in the trial had protective levels of tenofovir-based PrEP in their blood at a study visit three days after their vacation was over. Epi-PrEP may be a good option for some men with episodic high risk for HIV infection, and as an added bonus, “initiating PrEP on vacation may provide a helpful way to initiate long term PrEP.”
Oral tenofovir-based PrEP is still one of the most important tools for HIV prevention available today, but it is not a magic pill. Dr. Roel Coutinho reminded CROI attendees that using PrEP to eliminate HIV would take about 80 to 120 years without including other HIV prevention strategies. This is why viral suppression for people living with HIV is still a priority.
Findings from CROI:
So much information, so little time. This year’s CROI featured lots of research focused on women, hepatitis C, tuberculosis, anal cancer, and a host of other issues that will continue to be analyzed and reported over the next several months. My initial brain dump to frontline staff at APEB was intended to share information that they might find useful in their work with members of our community now. We’ll continue to develop workshops and presentations and events that attempt to keep folks armed with the latest information available and prepared for what’s coming next. Somewhere between “now” and “next,” we have a lot of work to do!