Background: Recent reports of declining donor financing for HIV underscore the need to mobilize increased domestic government spending. At the same time, countries vary significantly in their ability to absorb such cuts, making it critical for donors to carefully assess the vulnerability of countries to declines and scale transitions accordingly. However, to date, data needed to make such assessments have been quite limited. This study uses a new dataset to begin to answer these questions.
Methods: Using IHME''s new global dataset on estimated 2015 HIV spending by country, we identified spending by domestic governments, relative to other financing sources. We ran three scenarios of decreased donor support (2%, 5%, and 10% cuts) to assess implications for domestic government spending. Finally, we developed a “country vulnerability” scale based on the share of financing provided by domestic governments.
Results: In 2015, of the estimated $33.3 billion spent on HIV in low- and middle-income countries, half ($16.7 billion) was provided by domestic governments. This varied significantly, ranging from 10% in low-income countries to 84% in upper middle-income countries. Conversely, donor financing comprised only 11% of financing in upper middle-income countries, but 86% in low- income countries. The three scenarios highlight the differential impact of donor cuts. For example, a 5% decline in donor financing in low-income countries represents $342 million, or almost half of what those governments are spending on HIV ($780 million). A 10% decline represents $684 million, or 88% of what they are spending. At the same time, many middle-income countries, particularly upper middle-income countries, could offset cuts more easily, though there may be other barriers to doing so (e.g., equity, human rights and political concerns).
Conclusions: The ability to identify and track domestic government resources for HIV is essential for understanding the full HIV financing envelope and carefully managing country transitions. As this analysis shows, for some countries, even modest declines in donor financing would create significant challenges for governments. For others, absorbing such declines would be more feasible. The findings here provide a new tool for donors and others to help make such assessments.

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