Financial sustainability of HIV services for key populations in four countries in Asia: a mixed-methods study

Background

Across Asia and most of the world, there is a clear epidemiological rationale to scale up HIV services for key populations to meet national goals of ending AIDS by 2030. Key populations, such as men who have sex with men, sex workers, transgender people, and people who inject drugs and their sexual partners, account for 98% of new infections in the Asia–Pacific region.¹ The risk of acquiring HIV is 26 times higher among gay men and other men who have sex with men, 29 times higher among people who inject drugs, 30 times higher for sex workers, and 13 times higher for transgender people, when compared with the general population.^1,2Table 1 illustrates key epidemiological data from the four countries chosen for this study, including HIV prevalence by relevant demographic groups.

Since 2022, Health Equity Matters, a peak national organization in Australia for the community HIV response, implemented the Sustainability of HIV Services for Key Populations in Southeast Asia (SKPA-2) multi-country program funded by the Global Fund. It aims to improve the sustainability of evidence-informed, prioritized HIV services for key populations in Bhutan, Mongolia, the Philippines and Sri Lanka. These countries were selected for this study as they are all middle-income countries scheduled to transition away from Global Fund funding in the coming years. This transition is largely shaped by donor-driven priorities and a shrinking international funding environment, with eligibility thresholds set by major funders, for example the Global Fund, based on criteria such as World Bank income classifications and national disease burden. Despite increases in domestic funding of HIV programs and health systems, both in nominal terms and as a share of total investments, there is evidence that services for key populations are at risk when external donor–funded programs cease, and this has the potential to reverse recent gains made and fuel further new infections. As a result, countries undergoing transition, particularly those classified as middle-income, are experiencing service gaps for key populations, who are often excluded from national health budgets and remain heavily reliant on donor-funded programs. These global shifts place the sustainability of key population-led HIV services at risk at a time when increased domestic investment is urgently needed. These countries’ diverse socio-political and economic contexts, along with varying stages of HIV program resourcing, provide a valuable basis for comparative analysis. Additionally, although these countries share the challenge of transitioning from external donor support, their differing governance structures, health systems, and approaches to key population engagement offer a nuanced understanding of the barriers and enablers to sustainable HIV responses.

The UNAIDS (2020) Global AIDS Report noted that commitments by Member States to the Fast-Track target of providing 30% of all HIV service delivery through community-led organizations (i.e. organizations led by the community, where decision-making and direction come from the community itself) was currently unable to be measured.⁷ The assumption among global stakeholders is that this target has not been met. The shift to service delivery through community-led organizations faces barriers, including governments being reluctant to prioritize key populations (in an environment to operationalize universal health coverage), and community-based organizations (CBOs; organizations working within communities to address local needs) lacking the required legislative frameworks or credentials to partner for service delivery. At the same time, government officials need to understand CBOs’ role in key population services and build their trust in these organizations as service providers. Bhutan, Mongolia, and Sri Lanka do not have an established system for purchasing services from CBOs (‘social contracting’). The financial support to engage community-led organizations in the national responses critically comes from external donors such as the Global Fund.

In Bhutan, which has a low-level HIV epidemic where most historical infections can be traced to sex work,¹⁰ the Royal Government of Bhutan currently funds around 50% of the National HIV Strategic Plan, and government co-financing of the response has increased over time. However, Bhutan remains highly dependent on donor funding for HIV services for key populations, as programs covering the highest-burden priority districts are funded through Global Fund grants, and the government has yet to establish mechanisms to fund community organizations to deliver services for key populations.^3,5

In Mongolia, most new infections are among men who have sex with men, and the Global Fund also contributed around 50% of total HIV funding in 2021. Though government funding supports testing and treatment, government-funded services are targeted towards the general population and delivered through government health facilities. The new Health Insurance Fund in Mongolia ensures all people living with HIV (PLHIV) can receive free antiretroviral therapy, but funding related to HIV prevention services continues to be a challenge as these services are not covered by health insurance, and many key population members are unable to afford health insurance.⁵

From 2007 to 2022, HIV spending in the Philippines progressively increased, with domestic funding comprising a larger share of total HIV financing. International funding as a portion of HIV funding in the Philippines has declined to 10% of the total AIDS spending as of 2022.¹¹ The Philippines has other preconditions for sustainability, including legal and regulatory frameworks promoting community organization participation in HIV service delivery and Department of Health rules governing the accreditation of community organizations as implementing entities.¹² Despite the increase in domestic financing, the Philippines is dealing with a much larger epidemic than other SKPA-2 countries, and funding remains insufficient. Key challenges include realistic costing of and payment for services, and the inclusion of essential services such as prevention in social health insurance.¹³

In Sri Lanka, as of 2021, 48% of the National STD/AIDS Control Program (NSACP) budget is provided by external donors.¹⁴ The Global Fund finances all HIV self-testing, PrEP, and outreach in high-burden districts. These efforts, including the expansion of community-based HIV testing, have seen community organizations lead the way in identifying new people living with HIV in Sri Lanka. The country is emerging from a severe economic crisis, and the reliance on external donors for core HIV prevention services poses a serious risk to the control of the epidemic and the sustainability of the national response.

In this study, we aim to understand the barriers, such as unfit procurement systems and limited political will to domestic funding of key population–led HIV programming across Bhutan, Mongolia, the Philippines and Sri Lanka from the perspectives of a range of key stakeholders from the government to key population–led community organizations (i.e. organizations led by members of key populations, emphasizing their leadership and decision-making roles).

Methods

We conducted in-depth key informant interviews with 145 key informants, also referred to as stakeholders, and an anonymous online quantitative survey with 60 respondents (a sub-set of the key informant population), across the four countries. All participants were over 18 years of age and were recruited via email. Stakeholders were categorized on the basis of self-identification and targeted on the basis of organization type, categorized into four main groups: government staff, key population–led organization staff, NGO staff implementing HIV programs, and staff from multilateral organizations such as the United Nations. Stakeholders were listed by SKPA-2 sub-recipients and UN partners in each country, and a take-all approach was used to sample from these lists. The survey and key informant interviews were designed to allow non-sequential data collection, enabling participants to complete the survey either before or after their interview on the basis of their availability. This flexible approach accommodated participants’ schedules and ensured diverse perspectives. Ethical principles were followed in each country, including verbal informed consent, voluntary participation, and protection of participant confidentiality. As the data were collected and used as part of routine program implementation, and not categorized as research, submission to an Institutional Review Board (IRB) was not required.

Results

Key informant interviews included 60 government staff, 42 staff from key population–led organizations, 31 NGO staff, and 12 staff from multilateral organizations. The same participants who were included in the face-to-face interviews were given the opportunity and option to take part in the questionnaire. Sixty stakeholders responded to the quantitative survey out of 145 invited, with an overall response rate of 41%. This varied from a low of 37% in the Philippines (16/43) to a high of 50% (19/28) for Bhutan. A cross-section of participants from different stakeholder groups was recruited, as summarized in Table 2.

Discussion

Our research has identified and categorized the barriers to increasing domestic financing for key population–led HIV service provision across various stakeholders, from government to key population–led organizations. Knowledge and recognition that key population leadership is important was found across most stakeholder groups. However, we found a mismatch between recognition and sustained government funding to support key population leadership across all stakeholder groups. Contracting out key HIV services to CBOs (including HIV testing, outreach, PrEP, addressing stigma and discrimination and community-led monitoring) was supported by most government and key population–led respondents in the survey. This support is welcomed as research shows that key population–led HIV services such as PrEP and HIV testing are more cost-effective when compared with non-key population–led service delivery.¹⁹ However, the prospect of establishing ‘social contracting’ systems quickly may be unrealistic, given most government respondents estimate it will take 5–10 years before governments can afford to support the expansion of services with domestic funding. In countries such as Bhutan, sociocultural factors such as the government’s desire to limit the number of registered NGOs – due to concerns about the proliferation of NGOs in neighboring countries such as Nepal and India – highlight the delicate balance between fostering community-led services and political will. While governments acknowledge the importance of community-led HIV service delivery, these concerns can temper support for formal social contracting systems, as authorities seek to balance the benefits of community engagement with control over public service provision. These factors underscore the need for culturally tailored approaches to introducing social contracting. This timeline aligns with other contexts and countries where social contracting systems take years to set up and implement.²⁰ Similarly, we must look at the overall disease burden of HIV in these countries and the other disease areas competing for domestic funding resources within the national health budget. In the meantime, efforts to establish social contracting–related procurement capacity, systems and processes should be prioritized to ensure a smooth transition to contracting out community-based services once the funding situation improves. This may include building service procurement capacity among national HIV programs while facilitating the registration of key population–led organizations so they can manage finances and project performance aspects associated with performance-based contracts.

Although there are high levels of demand and understanding that HIVST and PrEP are important strategies among key stakeholders to ending AIDS, there is an urgent need to address access issues to ensure key populations can readily access these services. Governments can increase the involvement of CBOs by creating national registration and accreditation systems to enable them to deliver services, standardizing operating procedures and training modules on use of PrEP and HIVST tailored for key populations,^16,21 as well as expanding the role of private pharmacies and lay counsellors and community health workers in service delivery and access^21,22 as demonstrated in the Princess PrEP program in Thailand and a community-led HIVST program in Vietnam.^23,24 PrEP and HIVST services must be integrated into national testing strategies and guidelines and the government procurement budget.^16,17 National health insurance systems need to amend eligibility criteria for PrEP to make it available for wider vulnerable populations to cover the majority of key populations and to address gaps in insurance coverage for PrEP-related services.^21,22

Our study highlighted that stigma and discrimination remain a significant barrier in the included countries. While Mongolia’s historical legacy of Soviet influence has contributed to stigma, additional influences such as traditional gender norms and limited public awareness of non-heteronormative identities has perpetuated conservative attitudes toward LGBTQ+ individuals. This is consistent with existing literature that outlines how key populations face stigma and discrimination that affect their ability to seek HIV health services.^25,26 We found a disconnect between the high proportions of belief and understanding of the major impact stigma and discrimination have on accessing HIV services, compared with the available national or localized resources addressing stigma and discrimination for key populations. Despite this widescale recognition of the impact of stigma and discrimination on HIV services and prevention of new infection, rollout and success of stigma- and discrimination-reduction interventions are limited globally.²⁷ Stakeholders from all countries included mostly reported that local and national resources remain inadequate. Our finding that most stakeholders were unsure about or did not believe there was a functioning referral mechanism to legal services in case of patient rights violations or violence highlights that some international donor agency initiatives on safeguarding and rights are not trickling down to country-level implementation.

While the Global Fund and international donor agencies are decreasing their funding and moving to transition out of low-burden countries, the challenges and potential risks must be adequately assessed. Ren et al. analyzed and evaluated these potential risks for Vietnam, Lao People’s Democratic Republic and Myanmar and highlighted timelines, national health expenditure, burden of disease, and stigma and discrimination that may impact the ability of countries to fully transition to domestic resources following international donor withdrawal.²⁸ These are particularly illuminating and help support and understand some factors affecting stakeholders’ perceptions of transition timelines in Bhutan, Mongolia, the Philippines and Sri Lanka.

This study should be read with consideration of some limitations. The baseline assessment was conducted early in the program to ensure that findings and recommendations could inform SKPA-2 program activities. Thus, data collection periods for both quantitative and qualitative data collection were limited to between 1- and 4-week periods. Similarly, the response rates varied per country, and given that there are small sample sizes, these results should not be seen as representative of all stakeholders in each country. Nevertheless, our study provides important insights from a range of stakeholders. Although the survey was available in three languages, stakeholders might have been unable to participate if their level of English proficiency was low, including among some stakeholders in Mongolia, the Philippines, and Bhutan, so these results may be more illustrative of English-proficient stakeholders.

Conclusion

This study underscores the importance of identifying realistic timelines with key national stakeholders, including government and key population community leaders, in designing and deciding timelines for transitioning from international external donor support to domestic budgeting for key population–led HIV programming. Key population–led HIV programs have largely been developed and implemented using Global Fund support, and although transition planning has begun in all countries, setting up the systems and conducting adequate advocacy work may require an additional 5–10 years. Addressing the regulatory barriers and implementation gaps is key to facilitating this transition effectively and efficiently, ensuring that the set-up of the national system is fit for purpose and will continue once external donor support ends. It also highlights that although buy-in and understanding of key interventions is well known, there is a lack of sustained funding for these interventions that are paramount to promoting sustainability and working towards ending AIDS as a public health threat by 2030.

Supplementary material

Supplementary material is available online.