Revisiting aid dependency for HIV programs in Sub-Saharan Africa

Abstract Objective The overall increase in global domestic HIV expenditure obscures the specific performances of many sub-Saharan Africa (SSA) countries in local resourcing of their HIV programs. In this study, we explored the pattern and correlates of domestic HIV expenditure in SSA. Study design This is a cross-sectional ecological study. Methods Data were obtained from the Joint United Nations Programme on HIV/AIDS, World Bank, and the World Health Organization. We included 30 countries with available country-reported HIV expenditures between 2012 and 2017. From the most recent data, we examined the domestic (public and private) HIV expenditure as percentage of the total HIV expenditure. Using Spearman's rho, we assessed the correlation between domestic expenditure as percentage of the total HIV expenditure and HIV prevalence, antiretroviral coverage, gross national income (GNI) per capita, domestic general government health expenditure (GGHE-D) as percentage of general government expenditure, and GGHE-D per capita. Significant correlates at bivariate level were included in a multivariate median regression model. Results The median domestic HIV expenditure as percentage of the total HIV expenditure was 24.9% (interquartile range [IQR]: 8.5–39.3%). In 15 of 30 (50%) countries, domestic HIV expenditure as percentage of the total HIV expenditure was ≤25%. In 23 of 30 (77%) countries, public source accounted for >75% of the domestic HIV expenditure. There was a significant positive correlation between domestic expenditure as percentage of total HIV expenditure and GNI per capita ( r  = 0.52, P  = 0.003) and GGHE-D per capita (r = 0.494, P =  0.005). In the multivariate median regression model, only GNI per capita remained statistically significant (β = 0.006, P  = 0.004). Conclusions Some countries in SSA are still overly dependent on external support for their HIV response. Although increasing domestic HIV expenditure in these countries may require growth in the economy, governments can improve the fiscal space for HIV response by looking inward for innovative and sustainable funding mechanisms.