Press Release

HIV Prevention R&D Funding Drops Again, Even as Major Scientific Advances Require Support

A Worrying Trend Toward Overreliance on a Few Funders Increased in 2020

Contact

Kay Marshall, +1 (347) 249-6375, kay@avac.org

December 8, 2021 – The annual HIV Prevention Research and Development Investments Report reveals a growing mismatch between the current promise of HIV prevention R&D, and consistent declines in the funding available to both research new HIV prevention approaches and expand access to the prevention tools available today. The 2020 report, based on outreach to 215 funders of HIV prevention R&D in the public, philanthropic and commercial sectors, is the 16th annual report from the Resource Tracking for HIV Prevention Research & Development Working Group.

According to this year’s report, funding for HIV prevention R&D dropped by US$54 million (4.4 percent) in 2020. This second consecutive annual decrease is part of an eight-year trend of flat or declining funding for HIV prevention R&D. The report also finds that financial support for HIV prevention R&D is almost entirely dependent on public sector funders, notably from the United States, and on one key United States-based philanthropic funder, the Bill & Melinda Gates Foundation. Commercial sector funding, already extremely low, dropped again in this year’s survey.

“These concerning trends in funding come at a promising but very demanding moment in efforts to control the pandemic,” said Mitchell Warren, executive director of AVAC, which coordinates the Resource Working Group with the International AIDS Vaccine Initiative (IAVI) and the Joint United Nations Programme on HIV/AIDS (UNAIDS). “Funding is declining just as the field confronts a new generation of opportunities and challenges. These include the introduction of injectable cabotegravir for PrEP and the Dapivirine Vaginal Ring, ambitious new global targets for ending the epidemic, initial proof of concept of antibody-based prevention, and the need to rethink HIV vaccine development in light of setbacks in recent trials and the possible promise of mRNA and other vaccine approaches.”

Among the key findings from the annual HIV Prevention Research and Development Investments Report are the following:

HIV prevention R&D is highly overdependent on a few key funders, and much of the world is not contributing at the levels seen in prior years.

  • HIV prevention R&D funding relies almost exclusively on the public sector, particularly the US public sector. The trend toward an overdependence on a small number of large investors, which the Working Group has surfaced and cautioned against in the past, intensified further in 2020.
    • Globally, the public sector accounts for 86 percent of prevention R&D funding, with 92 percent of that coming from the US public sector.
    • European public sector investments represent only 7 percent of the global total. While European public sector investment increased by 57 percent in 2020, it is still barely half of the US$124 million the European public sector contributed in 2009.
    • The entire rest of the world accounted for only US$14 million, or just 1 percent of total public sector funding.
  • Philanthropic funding, consisting almost exclusively of funding from the Bill & Melinda Gates Foundation, declined 20 percent in 2020 to US$127 million or 12 percent of the total global investment.
  • Reported commercial sector support for HIV prevention R&D, already the lowest segment of investment, fell by 55 percent to US$31 million, or just 3 percent of the total, in 2020. While total commercial investment may be underreported, it is still the smallest piece of the HIV prevention R&D funding pie.

Funding dropped in 2020 across a number of key HIV prevention R&D segments, including:

Preventive vaccine R&D: With two large-scale HIV vaccine trials underway, and dozens of new approaches under investigation, funding for preventive HIV vaccine R&D decreased by 5.5 percent or US$46 million in 2020 to US$802 million. While different European countries have increased or decreased their investments, overall European public sector investment in HIV vaccine R&D decreased 31 percent in 2020, to US$48 million.

R&D for PrEP, including pills, implants and injections: While uptake of oral PrEP grew substantially in 2020, and multiple recent research studies have demonstrated the potential impact of PrEP in the form of long-acting injections, pills, implants and rings, global investment in PrEP R&D declined 2 percent in 2020 to US$107 million. While US public sector donors increased funding for PrEP R&D by 5 percent, and commercial sector investment increased by 21 percent to US$24 million, neither was enough to overcome a 42 percent decline in funding from the philanthropic sector.

Voluntary Medical Male Circumcision (VMMC): As a number of studies affirmed the efficacy of VMMC over a decade ago, funding in the field is focused on implementation science, behavioral studies and advocacy and policy, each of which is vital to extending the reach and impact of this highly effective prevention tool. Yet investment in VMMC decreased by 37 percent to just US$6 million in 2020, almost all of which came from a single donor, the Bill & Melinda Gates Foundation.

Preventing vertical transmission: Prevention of mother-to-child transmission of HIV (PMTCT) remains a key prevention priority, but funding for PMTCT R&D decreased by 29 percent in 2020, from US$35 million to US$25 million. The decline is attributed to the loss of the Bill & Melinda Gates Foundation from the list of PMTCT R&D funders, and to decreases in funding from public donors. US public sector funding for PMTCT R&D fell 22 percent to US$22 million in 2020. European funding also fell more than 60 percent, from US$3.4 million in 2019 to US$1.3 million in 2020.

Only two areas of prevention R&D funding showed small increases in funding, including:

Treatment as Prevention (TasP): Long neglected in HIV prevention investment, funding for TasP R&D increased from $1.7million to US$9 million in 2020. The increase came from philanthropy, notably the Bill & Melinda Gates Foundation (US$5 million) and the Wellcome Trust (US$1 million).

While TasP R&D funding is small overall, this increase is a hopeful sign that TasP may once again receive its appropriate focus as priority for HIV prevention research.

Microbicides: After multiple years of decline, investment in microbicide R&D registered a very small increase (0.4 percent or US$ 0.6 million) to US$145 million in 2020. Concerningly, there is even less diversity in microbicide funding than in HIV prevention R&D overall, with the public sector providing 99 percent of microbicide R&D resources.

While this tiny increase is a hopeful sign, it does not match the scope of the promise of this approach. One key product, the Dapivirine Vaginal Ring, is now recommended by the WHO as an additional HIV prevention option. In addition, a range of promising microbicide strategies are under investigation. One, a 90-day dual-purpose vaginal ring designed to confer both contraceptive and HIV protection, was found to be effective in early testing.

Pandemic preparedness requires greater investment in HIV, other current health crises

“The response to the COVID-19 pandemic has demonstrated that when there’s political will, global solidarity, and significant financial investments, rapid developments of new prevention technologies such as vaccines happen,” said Shannon Hader, deputy executive director of programme, UNAIDS. “This is the time to mobilize investments in HIV service delivery/prevention research and galvanize momentum to achieve the broader 2025 AIDS targets.”

Methodology: HIV prevention R&D investment figures are collected annually by the Resource Tracking for HIV Prevention R&D Working Group through an email survey. For the present report, the Working Group reached out from February to June 2020 to 215 funders in the public, philanthropic and commercial sectors. Two different types of resource flows were tracked: investments, defined as annual disbursements by funders; and, when available, expenditures, defined as resources directly spent on R&D activities by funding recipients. More information about the report methodology is at www.hivresourcetracking.org/about/methodology.

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About the Resource Tracking Working Group: In its 16th annual report, the Resource Tracking for HIV Prevention Research & Development Working Group (“Working Group”) documents research and development spending for the calendar year 2020 and analyzes funding trends spanning twenty years. The Working Group is led by AVAC in partnership with the International AIDS Vaccine Initiative and UNAIDS.

PEPFAR-Funded PrEP and VMMC Services in 14 Priority Countries

This infographic shows that PEPFAR’s increased investment and creation of a budget code resulted in improved scale-up of VMMC (VMMC). A budget code could have the same impact if applied to PrEP initiations.

Three Demands this World AIDS Day

World AIDS Day demands a lot of many of us. We must balance grief, worry and mourning with clarion calls to action and demands for accountability. On this day of private meaning and public mobilization, AVAC brings you a letter—to you, whoever and wherever you are, to all the leaders on the frontlines, in the halls of power and in the homes where caretaking and community mobilization happen. You can read our Letter to the World here.

In this letter, we’ve honed in on three things that feel essential to this present moment and the coming year:

1) Program for choice. For the first time in history, it is possible to build a choice-based biomedical HIV prevention program that offers a range of options. Today’s announcement that the World Health Organization has pre-qualified the Dapivirine Vaginal Ring brings this reality one step closer. But the full potential of choice-based programs depends on a client-centered, community-designed approach where people, not providers, decide what works for them.

2) Pay for the healthcare workforce to achieve health equity. From community contact tracers to counselors, community health workers, frontline nurses and physicians, it is essential to invest in well-paid, well-trained health workers who come from and have the trust of the communities hardest hit by health inequities.

3) Pursue just, equitable access for COVID-19 vaccines, therapeutics and community-led prevention. Each passing day brings news from COVID-19 vaccine trials, much of it highly encouraging. There is not a minute to lose in taking steps that guarantee new innovations—for COVID and HIV—will be available and affordable to all who need them.

Check out our full letter to learn more about how AVAC thinks these priorities can be achieved. And write us back—avac@avac.org—what do you care about and want to fight for? We’re here and listening and looking forward to continued advocacy together.

Voluntary Medical Male Circumcision for HIV Prevention (VMMC): An introductory factsheet

This introductory 2-page document explains how VMMC works, reviews the scientific evidence behind it, and outlines key advocacy issues for implementing it.

Learning from “Like” Products to Accelerate the Introduction of New Prevention Options

As part of an analysis funded by the OPTIONS Consortium (of which AVAC is a part), AVAC examined historical experiences introducing products that share characteristics with the dapivirine vaginal ring, specifically, products that were vaginally inserted and/or partially efficacious. Both are characteristics of the dapivirine vaginal ring and can represent a challenge to acceptance and use. However, products ranging from the rotavirus vaccine to the contraceptive ring have overcome these challenges. In our analysis – entitled The Dapivirine Ring: Key learnings from like-product introductions – we interrogate what facilitated their success and uptake, and conclude that with adequate planning and education, it is possible for products such as these to make an impact.

Developed by the International Partnership for Microbicides (IPM), the dapivirine vaginal ring is a silicone ring which looks similar to a contraceptive ring, but releases dapivirine (an antiretroviral drug) slowly over the course of one month. The ring is vaginally inserted, rests high inside of the vagina, and a woman can remove and reinsert the ring herself if she wants to. Also, its effect is localized (limited to the vagina) rather than systemic (affecting the whole body). The ring can give women control over their HIV prevention choices, without need to negotiate with or disclose to her partner.

Final results of the open-label studies HOPE and DREAM found the ring to be partially efficacious (with participants seeing a 39 percent and 63 percent reduction in HIV-risk respectively). These results were an improvement over the results of previous phase III trials ASPIRE and The Ring Study, in which the ring was demonstrated to reduce women’s risk of acquiring HIV by only 27 percent and 31 percent respectively.

Partially efficacious products and procedures have played a pivotal role in public health interventions for decades, and have been an important component of the HIV response for many years. For example, voluntary medical male circumcision (VMMC) is a well-known and effective tool for HIV prevention, and reduces the risk of HIV acquisition by 60-75 percent. The malaria vaccine and rotavirus vaccine are two other partially efficacious products that have become staples in prevention efforts.

In order to address concerns about partial efficacy, providers and implementers have employed a few key strategies. By focusing on interpersonal communication and using small groups to discuss the nuances of the products with both end-users and providers, it is possible to build confidence in a partially effective product. Product champions can also help drive up demand and acceptability of something like the ring. Integrating the ring with other health services may also draw new clients in and support uptake.

Researchers have noted that vaginal insertion of the ring has proven to be a barrier for some women, particularly due to lack of experience with these types of products in the African context and cultural norms which stigmatize female genitals.

The introduction of vaginally inserted products like the female condom, the progesterone contraceptive vaginal ring, tampons and the menstrual cup provide valuable lessons when considering how the dapivirine ring might be introduced. For example, peer-to-peer communications that include a product user can be effective in recruiting new users. Additionally, encouraging providers to try the ring themselves can help overcome provider bias. Acceptability of the ring among even a small group of vocal providers can influence uptake nationally, so those providers need to be found, encouraged and given a platform.

Finally, empowering women to explain the ring to partners, by promoting body awareness and knowledge of sexual and reproductive health, will be an essential component to ring introduction. To this end, education & communication (IEC) materials demonstrating how the ring fits in a woman’s body can alleviate concerns about the ring getting stuck or causing infertility.

With these strategies in mind, the HIV prevention field can better prepare for possible introduction of the dapivirine ring and ultimately help policy makers, health care providers and women interested in a new HIV prevention option make informed decisions about the ring. By clearly articulating the value of the ring as one component of the HIV prevention portfolio, and educating women and their providers about the benefits of a discreet and female-controlled prevention option, it is possible to accelerate the impact of the dapivirine ring in improving women’s health and reducing HIV incidence.

AVAC’s “3D” View of the World: 2019 and beyond

This infographic lays out AVAC’s top-line recommendations from AVAC Report 2019: Now What? The recommendations fall into three categories: deliver — prevention programs whose impact is well-measured and -defined; demonstrate — next-generation engagement for next-generation trials; develop — new targets for the post-2020 world.

UNAIDS Fast-Track Targets: The plan and the progress

The most widely-known UNAIDS Fast-Track goals were the 90-90-90 targets focused on diagnosing people with HIV, linking them to ART and supporting them to achieve virologic suppression. But these were only part of what the UNAIDS modelers said was needed to reduce new HIV diagnoses to 500,000 per year; the model also included significant scaling up of primary prevention including the targets listed below. There are gaps across the board, which helps explain how the world fell short of the hoped-for reduction in new HIV diagnoses.

Excerpted from AVAC Report 2019: Now What?

Visualizing Multisectoral Prevention: The DREAMS program theory of change

This is PEPFAR’s own visualization of how its AGYW programs can effect change. It’s notable for the definition of a care package that touches on the individual and her community, and for the way it defines a range of outcomes. There isn’t anything comparable for PEPFAR’s Key Population Investment Fund, which is infusing resources into a range of countries. Some of that funding is going for ART; for primary prevention, a theory of change linked to incidence is a must. AVAC is working with allies in KPIF countries to make this demand.

Excerpted from AVAC Report 2019: Now What?

AVAC Report 2019: With 2020 targets sure to be missed, we ask Now What?

Report cover

Today, AVAC released Now What?, our 2019 annual report on the state of the HIV prevention field. Each year, the AVAC Report frames the most pressing advocacy issues facing the HIV response. At the threshold of 2020, it’s clear that global goals for HIV prevention will miss the mark by a long shot.

Though important progress has been made, the crisis UNAIDS called out in 2016 persists today with new infections around 1.7 million annually, a far cry from the 2020 target of fewer than 500,000.

So, we asked ourselves, Now What?, and answered with cross-cutting analysis and an advocacy agenda to match.

FIRST, we call for leadership that is bold, visible and activist, from the new head of UNAIDS, to houses of parliament to civil society coalitions: take uncompromising stances, demand accountability, speak out for intersectional issues of race, gender, class and climate. This work needs to be funded, full-throttle and fearless.

SECOND, we call for the use of today’s most recent evidence to guide new prevention targets that will pave the way for epidemic control. Clear milestones for the prevention research pipeline must be set. Investments over the past decades have provided us with the prevention options we have today, and much-needed new strategies are under now investigation. The field needs targets for prevention research that people can understand and influence.

THIRD, we call for multilayered prevention approaches that are centered around the person, not the virus. Since last World AIDS Day, we’ve learned again, perhaps most strikingly from the ECHO trial, about the dynamic needs of women for HIV and pregnancy prevention. The complexity of translating results into policy, bring renewed urgency to the need for comprehensive HIV prevention and reproductive health approaches. Multilayered prevention incorporates multipurpose strategies (i.e., products that prevent both pregnancy and HIV) within programs designed to address structural barriers (i.e., policy reform, transforming community norms, facilitating educational empowerment).

2020 will be a pivotal year—join us in calling on leaders, from the grassroots to global capitals, to make 2020 a turning point, when siloes come down, crises are transformed by innovation, and prevention is center stage in the fight against HIV.

Happy reading, and we’d love to hear how you answer Now What?

What’s New on AVAC.org and PrEPWatch.org

We don’t want you to miss a host of resources posted in recent weeks on AVAC.org and PrEPWatch. In case you missed them, these tools and resources will sharpen your take on the field.

Reporting on Global HIV Prevention

Check out these reports—recently published by AVAC and partners—for updates on funding trends in prevention and cure R&D, as well as a fresh look at places that have beaten back HIV with existing interventions:

Smarter Rollout

These articles and tools support advocates, implementers and decision-makers working on PrEP rollout today with an eye on future interventions tomorrow:

  • Reaching and Targeting More Effectivley: The application of market segmentation to improve HIV prevention programmes, by AVAC’s Anabel Gomez and others, and published in the Journal of the International AIDS Society, explores how to leverage the power of market segmentation for the promotion and uptake of primary prevention.
  • Just updated in July, AVAC’s Global PrEP Tracker on PrEPWatch.org provides the latest data on programs, number of enrollments by country, regulatory status and more.
  • A User’s Guide to PrEP Tools offers a handy table to navigate the many tools produced by different organizations to support policy makers, implementers, providers and others on PrEP access, uptake and continuation. Use this table to learn more about these tools, who they’re designed for, and when to use them.
  • The PrEP4Youth video series of public service announcements encourages adolescent girls and young women in South Africa to consider PrEP as an HIV prevention method. Created by the OPTIONS Consortium in collaboration with the South African National Department of Health, these videos feature popular actresses and put young women at the center with short empowering messages.

Apply to be an AVAC Fellow in 2020

AVAC would like to remind you that our call for applications for the 2020 class of AVAC Fellows is open until September 20. We encourage you to learn more about the program and share this information with your network!