Dominant funders and their field-wide influence
HIV prevention research is primarily funded by a small number of large investors, a trend that the Working Group has identified and cautioned about in the past. 2020 saw this trend intensify even further: the US public sector contributed 79 percent of all global funding (US$857million of US$1.09 billion), while BMGF remained the principal philanthropic donor, accounting for 95 percent of all philanthropic sector investment (US$121 million of US$127 million). Together, the US public sector and BMGF accounted for 89 percent of overall funding, or 89 cents of every dollar spent.
The HIV prevention R&D agenda tracked by this report has grown over the decades to encompass a variety of biomedical interventions aimed, in most part, at primary prevention. Investment in this agenda measures billions of dollars in the making (US$20 billion since 2000), but it 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, 2019-2020
COVID-19 vaccines and HIV prevention R&D
With the unprecedented investment of over US$39 billion in 2020, collaboration and global resolve helped to catapult COVID-19 vaccines from testing to human use in just over a year. As of July 2021, more than a dozen vaccines had been authorized across over thirty countries, with many promising candidates in the pipeline, and almost 30 percent of the world population had received at least one dose of these vaccines. However, this distribution is far from equal across nations with differing resources, with only 1.1 percent of people in low-income countries having received at least one dose. The list of countries with the highest vaccination rates are largely Western, high-resource nations.
The three-decades-long, multi-billion dollar quest for a preventive HIV vaccine laid the groundwork for COVID-19 vaccine R&D. Advances in computational vaccinology, structural biology, 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 time. The converse may also prove to be 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 will hopefully 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 threaten to slow or stifle this momentum.
The global economy suffered losses of over US$12 trillion in 2020 due to the COVID-19 pandemic—over 300-fold what was reported as having been spent on developing safe and efficacious COVID-19 vaccines. Imagine: if early investments in HIV vaccinology had been commensurate with the threat, the savings to the global economy could potentially have been massive, in addition to millions of lives saved. 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 will help to alleviate suffering from existing pathogens like HIV, TB and malaria.
Fluctuating funding levels outside the US
2020 funding patterns across the globe demonstrate a hopeful diversification of support compared to previous years, observed by the increased number of non-US and non-public funders. From 2017 to 2019, the Working Group observed a decrease in the investment in HIV prevention R&D from non-US countries, down from US$74 million in 2017 (from 15 non-US countries) to US$71 million in 2018 (from the same number of countries) and steeply downward to US$48 million in 2019 (from nine non-US countries). In 2020, this trend reversed dramatically, with 16 non-US countries investing in HIV prevention R&D, totaling US$110 million.
Women-focused PrEP research
Complex forces related to discrimination and the oppression of women confer a heightened risk of HIV acquisition on women and girls. As of 2020, 53 percent of all people globally living with HIV were women and girls. Young women between the ages of 10 and 24 were twice as likely to contract HIV/AIDS as their male counterparts, and it remains the case that the majority of HIV transmission in women occurs via sexual intercourse with males. This disproportionate burden for women is exacerbated in socially marginalized populations such as female sex workers and transgender women. These continuing disparities call for the development of discreet HIV prevention products that are women-controlled and -initiated and are designed with the unique intersecting needs of women, adolescent women and young girls at the forefront.
In 2020, US$23 million was allocated specifically for women-centered HIV prevention R&D, defined as prevention options designed exclusively for women in all their diversity. Of this amount, US$5 million was allocated specifically for adolescent girls and young women, all related to PrEP research. US$2 million was dedicated to developing preventative methods for female sex workers, mostly in the field of prevention as treatment and a small amount in microbicides research. US$1 million was specified for PrEP studies focusing on transgender women, and US$0.6 was allocated for the prevention of vertical transmission, representing studies that focus on breastfeeding women, mothers, mother-and-infant pairs and pregnant women.
Clinical trials made up 33 percent of women-centered HIV-prevention R&D in 2020, while preclinical research made up 14 percent. A fairly even distribution of funding was observed for women-centered implementation science (17 percent), social and behavioral research (14 percent) and policy and advocacy (18 percent). Basic research only makes up two percent of all women-centered funding, which may point to a need for new, early-level innovation in the field of women-centered HIV prevention R&D.
Investment in Women-focused PrEP R&D, 2020
Spending on HIV/AIDS in the global context
Achieving a sustainable end to HIV/AIDS is featured prominently in the Millennium Development Goals (MDG 6) and the Sustainable Development Agenda (SDG 3), and enjoys broad support across bilateral and multilateral funding agencies. In 2020, Development Assistance for Health (DAH) for HIV/AIDS decreased 3.4 percent to US$9.0 billion6. DAH is defined as the financial or in-kind support from development agencies to low- and middle-income countries in order to maintain or improve health. Development agency support for HIV prevention R&D amounted to US$226 million, or 2.5 percent of total DAH, decreasing 5 percent from the 2019 level of US$239 million.