Dominant funders and their field-wide influence
HIV prevention research is primarily funded by a small number of large investors—a trend the Working Group has surfaced and cautioned against in the past. 2019 saw this trend intensify: the US public sector contributed three-fourths of all global funding (US$871 million of US$1.14 billion), while BMGF remained the principal philanthropic donor, accounting for 92 percent (US$145 million of US$158 million) of all sector investment. Together, the US public sector and BMGF accounted for 88 percent of overall funding, or 88 cents of every dollar spent.
The HIV prevention agenda is decades and billions of dollars in the making (US$19 billion since 2000), but is not invulnerable to shifting donor priorities or fluctuations in investment. A deeper, broader and more diverse funding base is vital not only for the long-term sustainability of the field, but also to ensure that valuable scientific progress is not lost to mercurial policy shifts.
Composition of the Global HIV Prevention R&D Investment Base, 2018-2019
Contributions from the Two Largest Donors, 2016-2019
(Percentage of overall funding)*
COVID-19 vaccines and the running start from HIV prevention R&D
The unprecedented investment of over US$39 billion in 2020, collaboration, and global resolve helped catapult COVID-19 vaccines from testing to human use in just over a year1. As of February 2021, eight vaccines have been authorized across dozens of countries with many promising candidates in the pipeline2. However, the process of developing a vaccine against novel SARS-CoV-2 did not start from scratch.
The three-decades-long US$15 billion-plus quest for a preventive HIV vaccine laid the groundwork for COVID-19 vaccine R&D. Advances in computational vaccinology, genetic and vector-based vaccine platforms, antibody assays and viral imaging were just some of the innovations first advanced by HIV vaccine science that were successfully repurposed to develop a safe and effective COVID-19 vaccine in record time3. The converse is also true: just as the cumulative gains from HIV prevention R&D laid the foundation for COVID-19 vaccines, cutting-edge platforms and technologies developed to combat the COVID-19 pandemic offer new tools in the quest for a vaccine against HIV and other infectious diseases.
If this momentum of heightened investment and collaboration in R&D continues, it will bring a new era of innovation in global health. However, flat funding for HIV vaccines since 2008 and the redirection of resources and expertise to COVID-19 threatens to stifle this newly unlocked potential.
The global economy suffered losses of over US$12 trillion in 2020 due to the pandemic4 — that’s over 300-fold what was reported spent on developing safe and efficiacious COVID-19 vaccines. Imagine, if early investments were commensurate with the threat, the savings to the global economy are potentially massive. Directing resources to innovation and R&D is the smarter, cheaper and more noble pursuit, one that will safeguard economies and lives from future pandemics, and help alleviate suffering from existing pathogens like HIV, TB and malaria.
Fluctuating funding levels outside the US
Non-US funding in 2017 came from 15 countries and totaled US$74 million. This number decreased slightly in 2018, with 15 countries investing US$71. In 2019, nine countries outside the US reported funding to the Working Group totaling US$48 million—a 32 percent decrease from the previous year. (Reporting from countries outside the US and Europe declined in 2020 which is when this analysis concluded. It is not clear if diminished reporting was due to disruptions from the pandemic or no relevant investment in HIV prevention R&D).
Prominent decreases came from the Netherlands (from US$6.2M to US$3.8), Belgium (from US$0.2M to US$0.04M), UK (from US$17.2M to US$16M), Germany (from US$7M to US$0.3M), Canada (from US$5.4M to US$5.3M) and France (from US$5.9M to US$5M). Funding from the European Commission decreased by two percent to US$9.3M.
Women-focused PrEP research
Complex forces related to discrimination and the oppression of women confer a heightened risk of HIV acquisition in women and girls and the data reflect that: Globally, 7,000 new HIV infections are recorded each week in adolescent girls and young women (AGYW). Girls aged 15-19 years make up three out of every four new HIV cases in sub-Saharan Africa5. This disproportionate burden calls for the development of discreet HIV prevention products that are women-controlled and initiated, and are designed with the unique intersecting needs of women and AGYW at the forefront.
One such option is PrEP, both in the currently-available oral form and in other long-acting delivery systems that do not require daily adherence. Out of the US$99 million invested in PrEP overall, US$26 million, or 26 percent, was for research explicitly focused on cisgender and transgender women. This is an increase from 2018 when US$23 million or 21 percent of overall PrEP funding was for women-focused research.
The majority of this research, i.e., 53 percent, was clinical and involved trials investigating long-acting PrEP formulations, sustained-delivery systems like implants, and multipurpose prevention technologies (MPTs) that combined pregnancy and HIV protection. Other clinical research involved evaluating the impact of gender-based violence, pregnancy and drug-use on PrEP uptake and continuation in women. Behavioral and social science research focused on PrEP adherence and systemic barriers to uptake in transgender women, female sex workers and AGYW.