The HIV Treatment Gap: Estimates of the Financial Resources Needed versus Available for Scale-Up of Antiretroviral Therapy in 97 Countries from 2015 to 2020

Background: The World Health Organization (WHO) released revised guidelines in 2015 recommending that all people living with HIV, regardless of CD4 count, initiate antiretroviral therapy (ART) upon diagnosis. However, few studies have projected the global resources needed for rapid scale-up of ART. Under the Health Policy Project, we conducted modeling analyses for 97 countries to estimate eligibility for and numbers on ART from 2015 to 2020, along with the facility-level financial resources required. We compared the estimated financial requirements to estimated funding available. Methods and Findings: Current coverage levels and future need for treatment were based on country-specific epidemiological and demographic data. Simulated annual numbers of individuals on treatment were derived from three scenarios: (1) continuation of countries’ current policies of eligibility for ART, (2) universal adoption of aspects of the WHO 2013 eligibility guidelines, and (3) expanded eligibility as per the WHO 2015 guidelines and meeting the Joint United Nations Programme on HIV/AIDS “90-90-90” ART targets. We modeled uncertainty in the annual resource requirements for antiretroviral drugs, laboratory tests, and facility-level personnel and overhead. Conclusions: The projected number of people receiving ART across three scenarios suggests that countries are unlikely to meet the 90-90-90 treatment target (81% of people living with HIV on ART by 2020) unless they adopt a test-and-offer approach and increase ART coverage. Our results suggest that future resource needs for ART scale-up are smaller than stated elsewhere but still significantly threaten the sustainability of the global HIV response without additional resource mobilization from domestic or innovative financing sources or efficiency gains. As the world moves towards adopting the WHO 2015 guidelines, advances in technology, including the introduction of lower-cost, highly effective antiretroviral regimens, whose value are assessed here, may prove to be “game changers” that allow more people to be on ART with the resources available. Arin Dutta and colleagues project global ART-related funding, global ART-related need under established targets, and the gap between the two.Background: AIDS has killed 39 million people since 1981, and over 36 million people (mostly living in resource-limited countries) are currently living with HIV, the virus that causes AIDS. HIV destroys immune system cells (including CD4 lymphocytes), leaving HIV-infected individuals susceptible to other infections. Early in the AIDS epidemic, most HIV-infected individuals died within ten years of infection. Then, in 1996, effective antiretroviral therapy (ART) became available. For people living in affluent countries, HIV/AIDS became a chronic condition, but it remained fatal for people living in resource-limited countries. In 2003, the international community began to work towards universal access to ART. Now, more than a third of people living with HIV are receiving ART, and the global death rate from HIV/AIDS is falling. The “90-90-90” targets recently set by UNAIDS—90% of all people living with HIV knowing their status, 90% of all people diagnosed with HIV infection receiving ART, and 90% of all people receiving ART having robust viral suppression by 2020—aim to end the AIDS epidemic by 2030. Why Was This Study Done?: Because early ART initiation both improves the health of HIV-positive individuals and reduces HIV transmission, the latest WHO guidelines (September 2015) recommend that people living with HIV should initiate ART upon diagnosis, regardless of their CD4 count. Previous WHO guidelines recommended initiating ART in certain populations based on CD4 count; for instance, the 2013 guidelines recommended adults living with HIV start ART only when their CD4 count fell below 500 cells/mm3 blood. Following the latest guidelines and meeting the UNAIDS targets will involve a rapid scale-up of ART, but are the financial resources available for this scale-up? Here, the researchers use mathematical modeling to estimate the numbers of people eligible for and receiving ART in 97 countries from 2015 to 2020 and the facility-level financial resources needed under three ART scale-up scenarios. Facility-level financial resources cover the costs of antiretroviral drugs, laboratory testing, and facility-level personnel and overhead (e.g., utilities, support staff, transportation, and other supplies), but not costs above the facility level or the costs of other services that are often integrated into ART provision. The facility-level ART costs are compared to the estimated financial resources available from domestic and external sources to assess the ART funding gap in the 97 countries. What Did the Researchers Do and Find?: The researchers estimated current ART coverage levels and future treatment needs using country-specific epidemiological and demographic data for 97 countries. They estimated annual numbers of people eligible for and receiving treatment assuming that countries continued to follow their current criteria for treatment (scenario 1), universally adopted aspects of the WHO 2013 eligibility criteria (scenario 2), or expanded eligibility to meet the WHO 2015 guidelines and the 90-90-90 targets (scenario 3) while increasing the percentage of persons reached based on historical rates. Under scenario 1, 25.7 million adults and 1.57 million children living with HIV could receive ART by 2020. Under scenarios 2 and 3, 26.5 million and 30.4 million adults, respectively, and 1.53 million and 1.68 million children, respectively, could receive ART by 2020. The estimated facility-level financial resources needed for ART scale-up from 2015 to 2020 were US$45.8 billion, US$48.7 billion, and US$52.5 billion under scenarios 1, 2, and 3, respectively. Finally, the estimated gap over six years between the resources needed for ART scale-up and the domestic and external financial resources available ranged from US$19.8 billion to US$25.0 billion depending on the eligibility scenario and the level of ART support provided by PEPFAR (the U.S. President’s Emergency Plan for AIDS Relief) and the Global Fund to Fight AIDS, Tuberculosis and Malaria, two major external ART funding sources. What Do These Findings Mean?: The accuracy of this study’s findings may be limited by the quality of country- and region-specific data, assumptions made about the funding available for ART, and the fact that only the facility-level costs of ART provision were considered. However, the estimates of the number of people receiving ART by 2020 suggest that countries are unlikely to meet the 90-90-90 treatment target (81% of people living with HIV on ART by 2020; that is, 90% of people living with HIV diagnosed and 90% of diagnosed patients receiving ART) unless countries expand ART access to all people living with HIV and rapidly increase coverage. Moreover, the estimated future resource needs for ART scale-up are large enough to threaten the sustainability of the global response to AIDS unless additional resources are made available through domestic or external financing sources or through efficiency gains. Thus, the researchers conclude, advances in technology and the introduction of new lower-cost antiretroviral regimens could be essential to allow more people to receive ART with the resources available. Additional Information: This list of resources contains links that can be accessed when viewing the PDF on a device or via the online version of the article at http://dx.doi.org/10.1371/journal.pmed.1001907.