Increasingly HIV prevalence is concentrated in middle income countries – UNAIDS estimates that by 2020, 70% of people living with HIV will be in middle income countries.

Many donors use gross national income (GNI) as the primary indicator for making investment decisions. As a result, when a country crosses the threshold to middle income country status, donors often reduce or end international development funding. This is based on the assumption that as GNI rises, the country is able to pay for its own development. However, GNI can give only a partial picture of a country’s ability to pay for its own development. It cannot measure a government’s willingness to provide services to politically unpopular key population groups (men who have sex with men, transgender people, sex workers and people who use drugs). It also cannot provide a measure of need within a specific sector.

The Equitable Access Initiative (EAI) convened by the Global Fund was set up to better understand countries health needs and capacities as they move along the development continuum. The EAI concluded that funding decisions should be based on a multi criteria framework including health and income indicators and should consider the domestic government’s capacity and willingness to invest in health. STOPAIDS supports the recommendations from the EAI.

Donors relying on GNI to make investment decisions, may choose to exit a country prematurely without ensuring a financed transition plan which guarantees the continuation of services for even the most marginalised groups is in place. If another donor or the domestic government is not in place to takeover services the result is a gap in HIV services. Key populations are disproportionately affected by the transition period as they are the groups domestic governments are least likely to take over services form. This is especially true in the presence of discriminatory or criminalising legal frameworks.

Case Study: Global Fund’s withdrawal from Serbia

Between 2003 and 2014 Serbia received $30 million from the Global Fund (GF) for HIV prevention and care. Global Fund support was used to scale up harm reduction programming. Funding ended in 2014 when Serbia became classified as an upper middle income country and its disease burden was assessed as only ‘moderate’. After the GF left, the national budget did not include any funding for HIV prevention for key populations. This reduction in funding seriously affected NGOs who deliver HIV services to key populations. For example An NGO previously reaching 3000 people who use drugs estimated they would reach only 500 PWUD a year after having lost GF funding. The government has maintained funding for the majority of Opiate Substitute Therapy centres, however it has drastically cut back needle exchange programmes.