The countries in this study spent just over a fifth of all resources for their AIDS response on prevention, providing a detailed picture of programmatic allocations of just over US$ 1 billion. While this analysis focused on prevention, these investments took place within the larger context of concurrent expenditures on treatment and care, orphans and vulnerable children, and program support and research, which brought total AIDS spending in 2008 to US$ 5.1 billion in the countries studied. Many of the prevention categories have low proportions of spending, but this does not necessarily mean that the spending is insufficient. This depends on the size of the target population and the amount that is spent. The recent Investment Framework proposes focused programs for high risk populations, elimination of HIV infections in children, reduction of risk through behaviour change, enhanced condom programs, treatment for people living with HIV and voluntary male circumcision in countries with high prevalence and low circumcision rates .
International funding is particularly prominent in prevention activities focused on MARPS, where it is the main source of overall funding, but it is likely that broader issues related to stigma, political will and human rights remain significant factors influencing domestic resource allocations. At least 42 countries in the study have laws criminalizing activities related to one or more MARPS . Decreased donor contributions will result in reduced funding for these groups and domestic resources do not often make up the gap. Sustaining long-term preventive services in these populations could present a serious challenge, particularly in low-income countries.
Of the 26 countries with generalized epidemics in the study, 25 are located in sub-Saharan Africa, a region which accounts for an estimated two-thirds of the global HIV epidemic . In these countries, it is essential to address sexual prevention, which have been reported as a key factor in the region's high levels of HIV transmission . This requires simultaneous implementation of a variety of risk-reduction strategies. A key approach typically relies on messaging targeting a particular sub-population. In the 22 countries with generalized epidemics that provided a detailed breakdown of their spending, mass media campaigns, community mobilization and workplace prevention programs together accounted for 27% of prevention spending. VCT received 17%, while 20% was invested in PMTCT and 5% was put towards ensuring a safe blood supply. Communication for behavioral change was the top prevention spending category in generalized epidemics. Uganda has experienced success through its 1987 "Zero Grazing" campaign and appears to have reduced the percentage of men having multiple partnerships .
Currently, there is wide interest in using antiretroviral therapy as a means to prevent HIV transmission [24, 25]. Evidence from PMTCT programs and follow-up studies of discordant couples has demonstrated a significant reduction in HIV transmission through ART . Preliminary results from the HPTN 052 study show that ART is 96% effective in preventing transmission to an uninfected sexual partner in discordant couples where the index case has CD4 counts between 350 and 550 . It is therefore plausible that early antiretroviral therapy and wide coverage could reduce community viral loads and significantly reduce the number of new cases of HIV [27, 28]. HIV testing can act as an entry point to both effective prevention and treatment, and bridge the gap between these two approaches.
Increasing consistent use of condoms requires strategies that go beyond supplying condoms to increase demand and motivation for their use. Roughly, four percent of spending in generalized epidemics was allocated to the provision of condoms, while 3% of resources were used for condom social marketing activities. A few countries in the region did direct a large proportion of their prevention resources to condom-programs.
In generalized epidemics in sub-Saharan Africa male circumcision accounts for a small proportion of overall spending, with only four countries reporting expenditures in this area. Male circumcision has been shown to be highly cost effective [29, 30]. A randomized control trial found that male circumcision has the potential to reduce the risk of HIV in men by 60% . The lack of spending in this area may be understandable, given that wide advocacy for this option really began in 2008. In June 2009, Population Services International received a five-year, US $50 million grant from the Bill and Melinda Gates Foundation to provide voluntary male circumcision services to 650,000 men in Swaziland and Zambia, while Zimbabwe has expanded a pilot program and is now aiming to circumcise 80% of its male population by the end of 2025 [30, 31]. There will likely be priority shifts and new trends in the future.
This study has several limitations; there is a lack of data to compare observed HIV spending levels with spending targets or populations at risk in the country. The data that do exist are highly unreliable and the authors determined that it was more instructive to present a global perspective of prevention than to compare spending to target population size. Also, expenditures are estimated using different sources of information and some countries lack comprehensive and regular expenditure records and accounting information systems. This analysis does not include out-of-pocket expenditures; although out-of-pocket spending has been found to vary from 23 to 68% of total health expenditures, the proportion that households divert to the purchase of condoms, HIV testing, clean syringes or other preventive interventions is unknown .