FINANCING THE HIV AND AIDS RESPONSE

Policy Brief on the 2013 HIV and AIDS budget Prepared by the Network to Stop AIDS-Philippines (NSAP)

Summary
The Philippines is facing a concentrated HIV epidemic that could lead to an estimated HIV prevalence of 35,900 to 46,500 by 2015. The rapid increase in new HIV cases has made the Philippines one of only seven countries worldwide with the highest increase in HIV cases. Reach of crucial HIV and AIDS services remains low. HIV testing is low among men who have sex with men and transgenders, including among injecting drug users. Risky behavior (unprotected sex or sharing of needles) is also common. Low coverage reects low investment. Scaling up of treatment in HIV burden sites like NCR, Cebu, and Davao, requires an investment of P1B for this year, but total spending from public and private sources is only P540M. Reliance on external sources of funds is not strategic. Global Fund, the main donor for the Philippines HIV programs, has cancelled its next round of grants. The country proposed for a two-year extension but the fundings approval is not yet guaranteed. Finally, even with Global Funds support, the funding gap still needs to be addressed. The P20M budgetary increase for the 2013 GAA is commendable, but it is not enough. The country needs P222M to reach the targets set by the national response.

Introduction: A fast and furious concentrated HIV epidemic The fast and furious increase in new HIV cases in the Philippines points to a worsening concentrated HIV epidemic in the country. While HIV prevalence is still low at .036%, the rise in new infections is exponential: the number of new cases has gone up from 1 new infection a day in 2007 to 8 to 9 new infections daily in 2012, bringing the number of reported cases to 10,242 by July 2012. However, based on the projection done by the Philippine National AIDS Council, the total HIV cases in the Philippines is estimated to be around 22,800 for 2012. The total cases is estimated to reach 35,900 to 46,500 by 2015.1 The global HIV pandemic is manifesting signs of a slowdown, yet the Philippines is one of only seven countries worldwide with the highest increase in HIV incidence in the last ten years. The main drivers of new infections are unprotected male-to-male sex (mostly in highly urbanized centers in NCR, Cebu and Davao) and sharing of needles among injecting drug users (mostly in Cebu). HIV prevalence among men who have sex with men and

HIV prevalence is the number of total HIV cases versus the total population, while HIV incidence refers to the number of new HIV cases. The main source of the gures above is the 2011 Philippine Estimates of the Most-at Risk Population and People Living with AIDS of the Philippine National AIDS Council. The high estimate for 2015 is from the presentation of Dr. Eric Tayag during the March 22, 2012 Plenary Meeting of PNAC.

transgenders (MSM & TGs) is already at 1.68%, while it has reached 13.56% among injecting drug users (IDUs).2 Low coverage of crucial HIV prevention, treatment, care and support services among these key drivers of the epidemic accounts for the rapid rise in new infections. Among MSM and TGs who engage in anal sex, only 23% have been reached by prevention programs. This is supported by data showing low condom use among MSM and TGs who engage in anal sex (36.2%) and poor reach of HIV testing in said community (5%). Among drug users, risky behavior remains rampant: only one out four uses sterile injecting equipment, and only 5% have undergone HIV test in the last 12 months.3

Low coverage due to low HIV spending To arrest and reverse the growing HIV epidemic in the Philippines, key HIV prevention, treatment, care and support services have to reach 60% to 80% of all most-at risk populations by 2016, a recommendation contained in the 5th AIDS Medium Term Plan (AMTP V), the countrys roadmap in addressing the HIV epidemic. These interventions need to be targeted in high burden areas, especially NCR, Cebu, Davao and Angeles City, and other urban areas that surround these epidemic hotspots where new HIV cases have likewise increased (Category B). A total of almost P1B is needed to reach the targets set by the AMTP V for 2013 just for the Category A areas.4 Ironically, despite the rapid increase in HIV incidence in the country, the combined total HIV spending from public and private sources is slowly declining (see table below). Year 2009 2010 2011 ! ! Total spending 573,122,069.90 563,684,723.90 545,365,110.07 (Source: UNAIDS-National AIDS Spending Assessment)

While the national government is slowly increasing its role in nancing the countrys HIV and AIDS programs, the Philippines remains largely reliant on external sources of funding, mainly from Global Fund for AIDS, TB, and Malaria (GFATM), the largest international donor for HIV and AIDS programs, and the private sector, mainly DKT International.
2 3

Source: 2011 Integrated HIV Behavior and Serological Surveillance

Unprotected anal sex is the most risky of all sexual activities, while sharing of needles is an immensely efcient way of transmitting HIV through blood-to-blood contact. Voluntary HIV testing is an important prevention intervention because HIV infection is asymptomatic. More data on coverage of existing HIV programs and other indicators may be found in PNACs 2012 Global AIDS Response Progress Report.
4

Source: HIV and AIDS Investment Plan 2011-2016 (PNAC).

Share of spending (in million pesos)

600 450 300 150 0 2009 2010 2011

Natl. Govt

Global Fund

Others

The decline in Global Fund spending can be attributed to the closure of two grants (GF Rounds 3 and 5). The remaining grant supported by Global Fund (Round 6) will end this November 30, 2012. Spending for prevention activities declined from 2011 to 2012. In 2011, national government spending for prevention accounted for 22% of total spending for prevention, higher than Global Funds spending for prevention activities. The private sector spent the most, primarily for behavior change and condom use interventions. (see table below)

Prevention spending Year 2009 2010 2011 NG 12,950,881.00 74,230,600.00 78,252,300.00 Global Fund 170,996,996.64 85,028,107.91 58,110,434.27 Others 135,184,179.18 202,458,028.43 211,063,115.33 Total 319,132,056.82 361,716,736.33 347,425,849.60

Meanwhile, from 2009 to 2011, the national government steadily increased its spending for HIV treatment, care and support interventions. In 2011, it accounted for 80% of all spending for treatment, care and support, while Global Fund, which in previous years has been the main funder of ART in the country, spent only P7 million for treatment.

Treatment spending Year 2009 2010 2011 NG 22,081,691.00 19,582,000.00 34,163,995.75 Global Fund 24,567,520.14 18,198,648.84 7,029,445.33 Others 2,763,386.14 511,440.00 1,018,893.00 Total 49,412,597.28 38,292,088.84 42,212,334.08

Of the P163M that the government reported to have spent for HIV in 2011, 47% went to prevention while 20% went to treatment, and the rest went to management and administration of the HIV programs, including surveillance. This displays the capacity of the national government to spend more on HIV programs, especially in light of a changing global landscape in HIV nancing. A looming funding gap In 2011, Global Fund announced the cancellation of its next round of grants (Round 11) due to the failure of donor countries to fulll their commitment to raise funds for the nancial institution. This development, along with the categorization of the Philippines as a middle income country, has increased pressure on the government to spend more for MDG commitments, including HIV and AIDS. However, to ensure that HIV programs in developing countries will not be disrupted while the Global Fund is searching for additional money to launch a new round of grants, a Transitional Funding Mechanism (TFM) was instituted to allow countries with existing grants to apply for an extension. However, the grant cycle for TFM is more competitive and rigorous. The Philippines, as a recipient of a Round 6 grant, applied for a $4.9M two-year extension under the TFM. The proposal, which is supposed to run from 2013 to 2014, aims to continue essential HIV services in Quezon City, Manila City, Pasay City, Cebu, and Davao City. It will fund key prevention activities such as peer education and outreach, especially for MSM and TGs and IDUs, and the procurement of anti-retroviral treatment. The proposal was recently approved as a Category 3 proposal, which means that the funding hinges on the completion of a claricatory process based on the conditions and issues raised in a technical review of the country proposal. The concerns raised by the Technical Review Panel (TRP) revolved around the low targets that were set in the proposal and the need to justify the cost for human resources and the management of the grant. The TRP also noted that in the absence of documents that can validate the governments compliance to the 20% counterpart nancing requirement for middle income countries, this, too, needs to be reviewed. What this means is that the approval of the TFM proposal is not yet guaranteed, and relying on it is not viable. In truth, even if the whole grant is approved, it would only

constitute 19% of the total funds that the country needs to scale up interventions in Category A areas. (See table below) TFM Year 1 (USD) Treatment Prevention Total 1,395,900.00 1,708,488.07 3,104,388.07 TFM / Investment Plan 23% 17% 19% Investment Plan CATEGORY A USD ($1=P40) 6,032,880.55 10,039,388.28 16,072,268.83 Php 241,315,222.00 401,575,531.00 642,890,753.00

If the country truly wishes to halt the spread of the epidemic, it simply cannot rely on Global Fund alone anymore. Allocation from the 2013 GAA National government allocation for HIV and AIDS is mainly lodged in several budget items in the Department of Health: the National Epidemiology Center (NEC), which covers surveillance; the PNAC Secretariat, which handles the day-to-day operations of the Philippine National AIDS Council; and the National AIDS/STI Prevention and Control Program. The latter implements most of the HIV and AIDS essential prevention, treatment, care and support programs of the national government. Its allocation is integrated under the budget item for infectious diseases, and for the 2013 GAA, it will receive a total of P85M.5 Of this amount, P35M or 41% will go to treatment (procurement of STIV/HIV drugs and reagents), while P15.2M will go to DOHs regional Center for Health Departments (CHDs) to support various prevention activities. P2.5M will be allotted for the procurement of HIV test kits, while P8M will be spent for the procurement of other HIV-related diagnosis and reagents. The rest of the amount will be allocated to other support services. The budget for 2013 marks a P20M increase from the 2012 allocation. The P35M allocation for anti-retroviral treatment is expected to cover the ARV needs of 6,056 Filipinos living with HIV.6 Meanwhile, the P2.5M allocation for test kits means that the government clinics will have around 30,000 HIV test kits for 2013. An alternative budget: How much is needed for 2013? The increase proposed by the Department of Health is a welcome development, as it signies an openness of the national government to invest more in our HIV and AIDS programs. The Network to Stop AIDS-Philippines, which has taken part in the Alternative Budget Initiative (ABI) that the DBM has mandated in partnership with a broad civil society platform, expresses its willingness to continue its constructive engagement with the government to scale up the countrys HIV and AIDS interventions. NSAP afrms that a
5 6

Source: NASPCP, DOH

Source: The Empowerment Budget of 2013 brieng on DBM Sec. Florencio Abad for the Malacanang Press Corp on July 10, 2012.

healthy collaboration between communities affected by and vulnerable to the HIV epidemic and our authorities is necessary to halt the epidemic. The budget proposal from NSAP is based on the following premises: 1. The interventions we need must be grounded on evidence, and thus NSAP supports efforts that focus on key populations, and in the current context, these are men who have sex with men and transgenders, sex workers, and injecting drug users. 2. As an issue of public health and human rights, the State has a fundamental responsibility to ensure that HIV and AIDS services, including treatment, are available and accessible, especially for the key populations. HIV treatment should be guaranteed to all Filipinos living with HIV, but we recognize that treatment alone is not enough - the government must spend and spend more for prevention. 3. The country response should engage the affected communities meaningfully so that barriers to life-saving services are removed and eliminated. 4. In order for these prevention services to be effectively implemented, systems have to strengthened and an enabling policy environment needs to be generated. The proposal below is aligned with the priorities of the Fifth AMTP and its sister documents, the recently approved MSM and TG National Plan and the Investment Plan. Thus, the proposal is pegged at reaching 80% of the key populations, a target that is based on the projections generated by PNAC to give the country the momentum it needs to halt the epidemic at the very start. The total allocation HIV and AIDS services for the 2013 scal year should be increased to P222 million. 63% of the proposed amount will go to prevention, and 26% will be spent for treatment, care and support. (See table below) Proposal Alternative Budget Budget items 1. Prevention STI Diagnosis and Treatment Condoms and lubricants Peer ed/BCC Voluntary counseling & testing Treatment, Care and Support 2. Systems Strengthening 3. Monitoring and Evaluation Total Proposed Budget 39,300,000 34,700,000 59,400,000 6,013,000 58,000,000 20,000,000 5,000,000 222,413,000 Sub-total Amount 139,413,000

Conclusion The rapid increase in HIV infections in the country sets the imperatives for the countrys response to the virus - we cannot be outpaced by the epidemic. The country is fortunate that it was able to detect the epidemic just when it has just started, giving it the opportunity to halt it and prevent it from spreading. We know that a general population HIV epidemic can be stopped if and only if we address the growing epidemic among key populations and vulnerable communities. The treatment cost alone of an unhampered HIV epidemic should give us perspective on the need to scale up our HIV services, and to scale up now: if nothing is done, if the status quo is maintained, by the end of term of President Benigno Aquino, the country would need P487M for treatment alone. We have all the tools and the evidence we need to halt the epidemic - all that the situation demands is the exercise of political will to spend what is necessary to put an end to the spread of HIV in the Philippines.

The Network to Stop AIDS in the Philippines is comprised of civil society organizations that are working in the national HIV response: Action for Health Initiatives (ACHIEVE), Inc; Alagad Mindanao (Davao); B-Change Foundation; Cebu Plus Association Inc. (Cebu); CrossBreeds, Inc. (Bacolod); Gayon Albay, LGBT Org. Inc. (Bicol); Health Action Information Network (HAIN); Lunduyan Foundation; Mindanao Advocates (Davao); Philippine NGO Council for Population and Development (PNGOC); Pinoy Plus Association; The Red Whistle; Sisters Plus (Angeles, Pampanga); TLF-SHARE Collective, Inc.; United Western Visayas Inc. (Iloilo); Vida Vivo Zamboanga (Zamboanga); and Youth AIDS Filipinas Alliance (YAFA).