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The fight is not over: making the case for burden sharing instead of burden shifting to keep the HIV and TB response on track

Dr Mit Philips, Kerstin Åkerfeldt and Dr Maria Guevara from Médecins Sans Frontières describe the global financial gap that could hinder the progress made in the fight against HIV and TB.


“I’ve been living with HIV for 15 years now. If I’m still in good health today, it’s thanks to antiretroviral treatment. But for several months now, there have been no more drugs. I’m having sleepless nights. I don’t know how we’ll get out of it. Before we started our treatment, we were told it was for life. But today, we feel abandoned in the middle of the road. We don’t know what to do.”

This testimony from Laetitia, in the Central African Republic (CAR), describes the impact of a stockout of life saving ARVs, caused by a series of challenges, made worse by the funding shortfall in the country. The situation reflects the unfinished business of the HIV and tuberculosis (TB) response, and is echoed by many patients, health workers, and programme implementers also in other countries where Médecins Sans Frontières (MSF) intervenes today.

Over the years, our teams, patients, and partners have directly experienced remarkable progress in the fight against HIV and TB. But the fight is far from over. In MSF-supported hospitals in the Democratic Republic of Congo (DRC), Guinea, Malawi and elsewhere, patients continue to die from HIV/AIDS, most within 48 hours of being admitted and often due to TB co-infection. Some patients have simply been diagnosed too late; others know their HIV status and have received antiretroviral therapy, but face treatment failure.

According to latest data from UNAIDS and WHO, 37.9 million people globally live with HIV and 10 million fall ill with TB every year. Today, both HIV/AIDS and TB are considered the world’s deadliest infectious diseases, killing over two million people per year; 770,000 deaths due to HIV, 1.6 million due to TB, of which 300,000 from co-infection. Moreover, mortality rates for both diseases have declined only minimally in recent years.

In this ongoing fight, the world needs to step up the pace even more. However, recent data indicate that national and global responses are in fact veering off track. Global political and financial investments have so far failed to align with the 2030 targets of ending AIDS and TB.  After many years of incremental increases in investment to fight HIV, funding from domestic and international sources for HIV programmes declined in 2018 for the first time since 2000, falling by a billion dollars in low- and middle-income countries. Meanwhile, the funding gap for TB programmes has widened further, reaching US$3.5 billion per year.

While funding shortfalls are not the only barriers to progress – factors that need to be addressed also include legal and cultural barriers, as well as restrictive policies – they risk undermining both gains made and political ambitions set. MSF teams describe both persistent and expanding gaps in essential prevention, diagnosis, and treatment services. These gaps include challenges in health facilities and staffing, stock-outs and medicine shortages, and shortfalls in programmes targeting people with specific needs such as those with advanced HIV disease, people who inject drugs and migrant populations.

When drugs and support services are lacking, it’s hard to continue your treatment and many people seeking care have to dig deep into their pockets to carry on with a treatment that should be free of charge. As a patient in this situation, how do you put your trust in the health system, and trust the healthcare provider with your life? And how does a well-intentioned health worker avoid to be discouraged in the daily struggle to provide quality care?

In countries such as DRC, CAR, and Guinea, needs and capacity for scale-up is outpacing the resources available; MSF has stepped in to provide support during recent stock-outs and shortages of antiretrovirals (ARVs) in CAR and Guinea. In Mozambique a financing gap for CD4 testing, essential to care of those with advanced HIV, resulted in the decision to ration use. In Eswatini, the country with the highest adult HIV prevalence in the world at 27% and one of the highest TB burdens, conservative estimates suggest the HIV funding gap will grow to US$ 24.9 million for 2020, and the TB funding gap to US$ 10.9 million by 2021. In Zimbabwe – facing a deep and acute economic crisis – the recommended scale-up of preventative TB therapy, especially for children and people with HIV, is dependent on additional funding.

Unfortunately, these gaps may be underestimations, because projections of increased domestic resources themselves risk relying on over-optimistic expectations.  Hopes for greater domestic investment may be laudable, intended to drive greater country ownership and financial independence from donor volatility. However, many countries still rely heavily on external support and are neither ready nor able to massively increase domestic resources in the short term to meet their population’s health needs and swiftly compensate for withdrawal of external funding.

As recently reported in The Lancet, many low and middle-income countries are unlikely to be able to replace even 10% of their current international contributions toward HIV/AIDS care and treatment. Moreover, there are serious risks in availability, optimal pricing, and quality of drugs, with an overly rapid shift of responsibilities to governments to purchase ARVs, TB drugs, and diagnostics. Furthermore, an overall lack of resources exacerbates existing tensions between prevention and treatment, pitting necessary and effective health interventions against each other, resulting in a rationing of essential health care to what is affordable but insufficient.

Undoubtedly, it is important to encourage the mobilisation of resources, domestic or otherwise, in ways that avoid placing the burden on patients. But risks associated with poorly planned and/or premature withdrawal of international funding must be carefully managed and mitigated. Donors must take a reality check. To ensure the global burden is shared, not shifted, it is therefore key to encourage continued and consistent international support to improve and expand the HIV and TB response.

As one of the most important international funding agencies for TB and HIV, the Global Fund has made the case, as part of its bid for its sixth replenishment, that merely continuing current levels of investment to fight HIV, TB, and malaria would lead to a rebound in incidence and mortality.[1] Evidence shows that where funding has been made available, results are more robust, and conversely that delays in tackling HIV and TB will mean higher costs for health, for people, and for economies, both in the medium and long term.[2] The Global Fund replenishment is a key opportunity for donors to show solidarity and address the funding shortfall, and its call for at least 14 billion US$ must be heeded, as a first crucial step in order to redirect the current trend.


The MSF report “Burden sharing or burden shifting? How the HIV/TB response is being derailed examines the HIV/TB financing situation in nine countries where the organisation is present:  the Central African Republic/CAR, the Democratic Republic of Congo/DRC, Eswatini, Guinea, Kenya, Malawi, Mozambique, Myanmar and Zimbabwe.  For more information, go to


Dr. Mit Philips is Health Policy Advisor at the Analysis Department of MSF in Brussels. Currently her main focus of work at MSF concerns HIV, health care in crisis and ‘fragile contexts’, trends in global health and health systems policies, financial barriers to health care and health financing, the health workforce crisis.

Mit is a medical doctor and has a Masters degree in Public Health from the London School of Tropical Medicine and Hygiene and a diploma in Tropical Medicine from the Antwerp ITM.

Competing interests: none to declare

Kerstin Åkerfeldt is a Health Policy & Advocacy Advisor in the Analysis Department of the MSF Operational Centre Brussels. She is the liaison for the MSF movement with the Global Fund, and supports MSF operations with policy analysis and on advocacy matters related to the three diseases and global health financing.

Kerstin joined MSF in 2002. She has a Masters degree in International Studies from Uppsala University.

Competing interests: Kerstin is a member of the Developed Country NGO delegation to the Global Fund board.

Dr. Maria Guevara is a Senior Operational Positioning Advisor on Global Health and the lead for the Planetary Health working group for MSF in Geneva. Her work experience in the humanitarian sector began with MSF in 2004 in various field roles.

Dr. Guevara was trained in Pulmonary and Critical Care Medicine at the University of Florida in Gainesville.  She has also received a Diploma in Tropical Medicine and Hygiene at the Liverpool School of Tropical Medicine and a Master of Science in Global Health Policy from the London School of Hygiene and Tropical Medicine.

Competing interests: none to declare

Photo credit: Pablo Garrigos/MSF

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