One Timeline, Two Stories, One Message: Putting trials and targets together

One problem with HIV prevention agendas is that they either live in an eternal present or in a far-off future. It’s “work with what we’ve got, which is condoms and VMMC and a little bit of PrEP”, or it’s “nothing can change without an AIDS vaccine”. The future depends on using what’s available, better and more widely, without ever losing sight of what’s in the pipeline.

As the figures below show, in the very same timeframe that the world will miss its critical target for incidence reduction and scale-up of primary prevention, several trials will release results that could change the future. 2020 will be a time of hope and reckoning. But only if the two stories start to be told as one.

Global HIV Prevention R&D Investment by Technology Category, 2000-2017

In 2017, reported funding for HIV prevention R&D decreased by 3.5 percent (US$40 million) from the previous year, falling to US$1.13 billion. The full report, HIV Prevention Research & Development Investments 2017: Investing to end the epidemic, is available for download. And all the graphics are available as well.

HIV Prevention R&D Trial Participants by Region in 2017

Participation of volunteers and the engagement of communities in which trials take place is essential to conducting HIV prevention research. In 2017, there were nearly 600,000 participants in HIV prevention research trials globally, mostly originating from sub-Saharan Africa, Europe, North America and Asia. A majority of participants were enrolled in research investigating TasP and PrEP, and while there are trials aimed specifically at men who have sex with men (MSM), transgender individuals and people who inject drugs, most of the studies do not specify the need to include members of key populations.

The full report, HIV Prevention Research & Development Investments 2017: Investing to end the epidemic, is available for download.

Investment in HIV Prevention R&D by Top Philanthropic Funders in 2017

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.

Prevention Research Funding Report 2017: Investment slows and continues to concentrate in a few funders!

[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

Continued declines in HIV research funding put global prevention targets at great risk

Contacts

AVAC: Kay Marshall, [email protected], +1-347-249-6375
IAVI: Anita Kawatra, [email protected], +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.

###

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.

Global Number of New HIV Infections, 2000-2017 and 2020 Target

1.3 million person gap between the current rate and the 2020 target.

Peers are Primary: Towards a systematic approach to lay cadres

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.

Towards a Demand Creation Cascade

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.

Putting Women at the Center: Informed choice in 2018 and beyond

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.