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South Sudan relies heavily on external donors who fund 97% of the projected US$ 50 million annual AIDS response investments, with PEPFAR and the Global Fund providing approximately 66% and 30% of the HIV budget in South Sudan, respectively. The government of South Sudan has typically allocated a small budget of 2.0% to health (including HIV) annually, primarily for staff salaries, with no funds allocated for service delivery, commodities, or other functions. Currently, there are no other development partners supporting core HIV programs in South Sudan.  These HIV funds from the Global Fund and PEPFAR continued to be provided even with COVID 19. In fact, additional resources were provided by the Global Fund to strengthen the health system with direct positive impact on HIV service delivery. In addition, the IMF’s special drawing rights (SDRs) have helped ease fiscal pressures. The authorities used US$150 million from the SDR allocation to finance spending, mostly to reduce salary arrears.

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The COVID-19 pandemic impacted the national health system in terms of available ot health products/resources. Health personnel, infrasture and even budget were diverted to address the COVID pandemic. Many people living with HIV reported long waiting lines and difficulty in access HIV services due to this diversion of resources. However, the Ministry of Health did implement normative policies to prioritize people living with HIV to receive the vaccine and adopted multi-month dispensing. Fortunately, the budget has stabilized for direct services but human rights programmes. COVID-19 also put a strain on social services and for the first time in many years, Brazil reported in increase in malnutrition and hunger. The UN also redirected funding to regions greatly affected COVID-19. Other impacts on heath financing have been more related to political opporition but not COVID-19. The post COVID-19 impacts have been seen in rise in the cost of living, inflation, and food.

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COVID-19 pandemic brought the following challenges for HIV investment:
- Health budget was prioritized to attend the pandemic and this impacted negatively in the availability of funds for HIV response.
- Some development partners and donnors reduced their contributions to key programs for HIV response such as treatment/care, prevention (emphasis in key populations) and human rights related matters.
- Inflation impacted in the increase of prices of health commodities.
- Importation of HIV commodities was also affected as COVID-19 supplies were priotitized.

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Nuha Ceesay, UCD Malawi-Challenges Posed by COVID19 on HIV Financing 

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Nuha Ceesay, UCD Malawi-Challenges Posed by COVID19 on HIV Financing 

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The COVID19 pandemic brought about unprecedented challenges in almost all aspects of development globally and Malawi is no exception. The first case was reported around April 2020 and government immediately initiated measures to restrict the further spread and potential impact on health and the economy.

Those initial measures were challenged in court and an injunction granted that resulted in Malawi not imposing any total lockdown.

In the HIV response, the immediate steps were to further review the service delivery modalities and institute measures which resulted in the scaling down of HIV prevention services.

The impact on HIV financing was noted in the high cost of freight and transportation of medicines as the means of transportation was mainly through cargo.

The other negative impact of COVID on HIV was the repurposing of funds allocated for HIV to respond  to COVID19. This has resulted in a reduction of funds earmarked for HIV to be redirected to COVID19 and affected meeting a number of targets set.

The testing platform such Gene X-Pert machines were also used for COVID 19 and this affected the viral load monitoring and routine HIV testing services. Health workers, nurses, doctors, laboratory staff and community health workers were also redeployed towards the COVID19 services and this invariably affected HIV services.

While the advocacy for increased domestic funding was gained momentum in Malawi, the COVID19 pandemic resulted in further constraints in the fiscal space and ODA shrank as most donors were equally dealing with the same challenges in their own countries.

The recovery pace was slow as Malawi was also affected by climate and weather related disasters which resulted in considerable damage to the health infrastructure, many people displaced and hence needing emergency and humanitarian assistance.

The advocacy for sustainable financing and increased use of domestic resources had to be stalled given the major strain caused by COVID19.

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In terms of HIV investments, the C19 pandemic caused major delays in implementation of both Government and external donor funded HIV initiatives. In a number of instances this stalled/delayed the transition from externally supported initiatives to domestic implementation and funding. As the entire Government health system pivoted to get ahead of C19, services and bottlenecks in the existing system and linked to HIV were shelved or postponed. Funds for new initiatives were also sidelined as C19 took priority.

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Although COVID-19 diverted attention and resources from previous priorities, but thru UCO acumen became an opportunity for further resource mobilization for NGOs/communities and also drawing attentions to marginalized people. Inclusion of PLHIV/KPs in the national prevention an treatment guideline for COVID-19 as one of most at risk populations vulnerable to consequences to COVID-19, mobilizing NGOs to establish workshops to produce PPEs, running RCCE campaigns, HIV/COVID IEC material production and communication by and for the communities and sharing experience of HIV in addressing COVID needs including S&D were among opportunities seized by turning threats.

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South Africa’s domestic economy contracted severely from the effects of the COVID-19 pandemic, exacerbated by low economic growth, extreme unemployment, a high debt servicing costs, the national energy crisis, and unexpected shocks, such as unrest and floods in some parts of the country in 2021. The government is expecting economic growth in the medium term, but fiscal space for health is expected to remain constrained. The government’s austerity approach to spending in the last few years has resulted in cuts to the baseline budgets of all government programmes and the introduction of measures to realize efficiencies. Between 2019-20 and 2022-23, the annual value of the health budget declined by approximately R3.2- billion. According to analysis the government will spend about R332.80 less per health user in 2023 in real terms than it did in 2019. Domestic HIV and TB programmes, drove approximately 13% of total public health spending in 2019/20. The South African government spent R29 billion on HIV and TB in 2019-20, comprising 71% of total expenditure on these diseases (a decrease in share from 2017-2018 of 73%). Budget allocations to the HIV and TB conditional grants for the 3-year 2022 MTEF period show a small decrease in real terms. The conditional grant components for HIV, Tuberculosis, Community Outreach Services and HPV immunisation were restructured in 2022. The total of R81.8 billion for these components for the 3-year MTEF period is more than R6 billion less than what was allocated under the 2019 MTEF. The Department of Basic Education’s HIV and Life Skills programme as well as the Department of Social Development’s HIV programme also reflect similar baseline reductions to the department of health, both showing declines in funding in real terms over the medium term. Although recent allocations to South Africa from both PEPFAR and the Global Fund have increased as they support South Africa to intensify efforts to reach 95-95-95 for HIV and TB, policies and actions from both development partners strongly encourage upper middle-income countries such as South Africa to increase domestic funding in key areas and to systematically plan for the transition of select externally funded functions to the public sector. However, the fiscal space for increased spending on health over the next 5-years will remain constrained. South Africa and its external and private sector partners will need to invest smarter, and in harmony, based on economic evidence; and just as importantly spend efficiently to ensure that the goals of the new NSP are achieved. Innovative funding platforms created during the height of the COVID-19 pandemic are being adapted to provide additional, complementary funding for HIV, STI and TB interventions.

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Coronavirus disease 2019 (COVID-19) was first detected in December 2019. In March 2020, the World Health Organization declared COVID-19 a pandemic. People with underlying medical conditions may be at greater risk of infection and experience complications from COVID-19. COVID-19 had the potential to affect People living with HIV (PLWH) in various ways, including be increased risk of COVID-19 acquisition and interruptions of HIV treatment and care.
Mozambique being classified among the less developed countries in the world and as such suffered deeply the health and economic brought by the Covid.

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The COVID-19 pandemic brought additional challenges in terms of HIV investment in Morocco. Resources, both financial and human, were redirected towards combating COVID-19, resulting in a reduction of funds and efforts dedicated to HIV prevention and treatment. Additionally, movement restrictions and lockdown measures made it harder to access HIV prevention, testing, and treatment services, particularly affecting already marginalized key populations. Thus, the COVID-19 pandemic exacerbated existing challenges in HIV investment in Morocco, highlighting the need for a more integrated and resilient approach to health systems.

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COVID-19 impact on HIV investment (Pakistan)

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COVID-19 impact on HIV investment (Pakistan)

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In the context that already faced financial constraints, COVID-19 exacerbated the country’s macro-economic conditions, further limiting prospects for increasing domestic investments in HIV. “Pakistan is experiencing severe economic challenges reflecting long-standing structural weaknesses” and “Pakistan’s economy is currently under severe stress with low foreign reserves, a depreciating currency, and high inflation.” (World Bank)

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COVID-19 impacts on HIV investment- Martin, Tanzania

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COVID-19 impacts on HIV investment- Martin, Tanzania

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The COVID-19 epidemic affected availability and quality of HIV services.  There was reduced access to food most especially impacting vulnerable populations.  Children’s rights (child labour and teenage pregnancies) were impacted. School attendances reduced.  Negative social behaviours increased the risk of HIV especially among the vulnerable. Family and child care was impacted negatively. There was reduced income and increased unemployment. Global Supply Chain challenges affected HIV commodities' security.

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COVID19- induced challenges for HIV response in Guatemala

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COVID19- induced challenges for HIV response in Guatemala

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The pandemic necessitated a redirection of healthcare resources towards the COVID-19 response, including funding, personnel, hospital beds and medical supplies. This diversion of resources led to a reduction in resources available for existing health programs, including those related to HIV.

Lockdowns, travel/movement restrictions and transportation difficulties, supply chain disruptions/delays, limitations on community based outreach activities, fear of COVID infection and healthcare facility closures disrupted routine healthcare  and HIV services.

The economic crisis generated by the pandemic meant people had less resources to access health services, afford exams and medications, and engage in preventative measures.

Global economic pressures resulting from the pandemic impacted donor funding to health and development programs.

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The COVID-19 pandemic has heavily impacted Chad economic growth and the wealth of the communities. This situation led to rechanneling the national budget and other donors’ aid to respond to the pandemic. Respond to COVID-19 pandemic was another competing priority faced by HIV investment.

In addition, the pandemic has impacted the programmatic gains which need more investment to reach the level before the pandemic. This additional investment for the recovery of AIDS response could not be mobilized as national budget and donors’ resources were tight.

In Chad, households contributed an average of 65 percent to total health expenditure and the lockdown during COVID-19 has increased the poverty level and hindered access to health services including HIV prevention, care, treatment, and support services.

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In general, the COVID-19 pandemic has had a devastating impact on the fight against HIV. Some progress was still made, but other key programmatic results declined.

However, the worst was avoided after the initial fear of the second and third and third quarter of 2020  :

- Treatment continuation was strengthened through rapidly scaled up multi-month distribution (MMD) and community distribution of vital ART

- Other essential HIV services were further decentralized to communities

- The national government put in place a national social protection scheme that helped a lot of Togolese families (‘Novissi’ linked to an innovative automized payment platforme)

- Support through WFP for PLHIV families

- GF and PEPFAR for HIV and WB, FMI, EU, … provides essential complementary funding
- ...

So, the immediate impact of COVID19 seems to have been mastered quite well by togo.

However, the post COVID-19 period may not go so well with the following threats:

- slower economic growth, higher inflation and worsening debt risks

- the security threat in the north of the country

- climate change provoking heavy rains
We have to see how other additional measures from partners and government may help to address the impacts on the most vulnerable people in society.

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The crisis of the Covid-19 pandemic and its impact on investments in HIV in Argentina. Alberto A Stella - MCO Souther Cone

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The crisis of the Covid-19 pandemic and its impact on investments in HIV in Argentina. Alberto A Stella - MCO Souther Cone

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The covid-19 pandemic had a severely negative impact on the economy with an exponential increase in multidimensional poverty, especially in provinces with lower levels of development, creating a context of greater inequities. This exacerbated the debt crisis and the country's economic growth slowed, significantly increasing inflation. This resulted in the redirection of resources, human, infrastructure and financial, to the Covid crisis.
All of this had a severe social impact, especially on the most vulnerable people. The State had an immediate emergency response and prioritized the most vulnerable populations, including PLHIV
Although Argentina has a social environment with lower levels of stigma and discrimination compared to other countries in the region and has a legislative framework that protects human rights as well as a social protection framework, the levels of stigma increased as well as violence. gender based.
This context has been an important challenge for the country, whose government has responded positively with social policies and without neglecting the implementation and territorialization of the 2030 Agenda.

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HIV investment challenges due to the Covid-19 pandemic in Mali.

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HIV investment challenges due to the Covid-19 pandemic in Mali.

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In Mali, as in many developing countries, the Covid-19 pandemic had a negative impact on the national economic growth.
1. The consequence was the decrease of the GDP, the reduction of the fiscal space and the shrinkage of the domestic resources.
2. At the same time
many bilateral and multilateral donors have redirected their financial support to fight the Covid-19 in the detriment of HIV response.

3. The combination of these factors is that there was less resources and investment for the AIDS response during the Covid-19 pandemic.
4. In response to the unexpected situation, the national authorities developed and implemented a national emergency plan to address the Covid-19 pandemic including measures of mitigating for current pandemic such as HIV. The objectives were to reduce the Covid-19 impact on the ongoing programs (HIV/TB, Malaria) funded by the Global Fund and PEPFAR.  This plan comprises social protection interventions for poor and marginalized populations. The rights for all to access to the treatment and vaccine was at the center of this emergency plan.
5. For the HIV, People living with HIV received funds for generating revenues activities including awareness campaign on HIV and Covid-19 prevention. Counselling and psychologic supports have been strengthened for PLHIV and key populations. The Multi-Month-Dispensations of drugs distributions has been implemented.
6. Despite these mitigation measures, the testing and treatment performances were dropped down because of the insufficiency of human and financial resources and the limitation of access to health facilities due to the contingency measures and confinement put in place.

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Covid-19 pandemic crisis and its impact on HIV investments: Richard AMENYAH (Jamaica)

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Covid-19 pandemic crisis and its impact on HIV investments: Richard AMENYAH (Jamaica)

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·      The covid-19 pandemic worsened the debt crisis and disrupted economic growth in the country. This resulted in critical cuts in the budget across all sectors to finance the covid response and hence limited the fiscal space for HIV investments further.

·      The lockdowns and travel restrictions resulted in the collapse of tourism and local production of food. Hence government revenue further declined which led to knock-on effects in social investments including for HIV.

·      The covid crisis led to the prioritization of people most at risk of infection and death especially the elderly and people with noncommunicable diseases (NCDs). This somehow contributed to deprioritization of HIV for NCDs. However, the lessons learned from HIV were effectively leveraged to fight covid.

·      Stigma and discrimination towards vulnerable populations such as people living with HIV, LGBTQI+ communities, and marginalized groups resulted in them being disproportionately affected by the COVID-19 pandemic such as inadequate social protection measures.

·      It is important to point out that while the COVID-19 pandemic has had a significant impact on HIV investments, there were efforts to mitigate these effects. Contingency planning resulted in robust adaptative measures in service delivery, telemedicine, and community-led responses to ensure continuity of HIV services amidst the pandemic.