The number of people living with HIV worldwide has continued to grow, reaching 33.4 million in 2008. In the same year 2.7 million new HIV infections occurred, almost half (45%) among people younger than 25 years . Despite a more than eight-fold increase of total global financing for fighting AIDS, from 1.6 billion US$ in 2001 to 13.8 billion in 2008, a small fraction has gone to HIV prevention . Public donor expenditures for treatment have grown much faster than the spending for prevention [3–5]. The two largest public AIDS funds, the Global Fund for HIV Tuberculosis and Malaria (GFATM initiated in 2001) and the Presidents' Emergency Programme for AIDS (PEPFAR since 2003), spend about 70% and 80% of their respective HIV budgets on treatment and care programmes in developing countries [6, 7]. However, as of December 2008, mainly due to the high costs of treatment, 58% of those infected and requiring antiretroviral treatment cannot access such treatment . Prevention, to halt the increase in new infections, therefore, remains as urgent as before. HIV experts currently agree that prevention is underfunded . Therefore, insight into how the limited public funding for prevention is distributed is important.
At the end of 2008, for every two people starting antiretroviral treatment, five were newly infected . Even if there were a cure for HIV, treatment only would by no means suffice to control the epidemic . Although, HIV infection is avoidable, HIV prevention interventions are estimated to be accessible to fewer than one in five people worldwide . Similarly, less than 40% of young people in developing countries are estimated to have basic information about AIDS and HIV prevention . This knowledge gap might be due to the frequently expressed objections of political and religious leaders to sexual behavioural change programmes known to reduce HIV infection rates, such as integrated condom programming . The same leaders, however, seem to be eager to welcome donor support to antiretroviral treatment for their populations . The knowledge gap on prevention is reproduced on another level. Only a limited number of studies provide information on the coverage level of HIV prevention programmes in different developing countries , while ample data are available on the coverage rates of treatment and care programmes . Public funders could play a crucial role in supporting developing countries to extend the coverage of evidence-based HIV prevention programmes. So might private and philanthropic donors, but due to lack of information on these funding streams they are excluded here from the analysis.
Within HIV prevention, different approaches can be distinguished, such as prevention by vaccines or microbicides, prevention by integrated condom programming, and some recently introduced prevention technologies such as male circumcision and prophylactic use of antiretroviral drugs. Prevention by vaccines or microbicides has been considered an important means to stop the AIDS epidemic since the beginning of the 21st century. Recently, the director of UNAIDS expressed his belief, that a preventive HIV vaccine holds the greatest opportunity for ending the epidemic and many share his view . Several scientists, however, among them the chief editor of the Lancet, seriously question the possibility of developing a successful HIV preventive vaccine and criticise the overly optimistic prospect portrayed by the vaccine research community . In 2007, five large-scale HIV vaccines studies were stopped because they failed to show satisfactory results . In the same year, two microbicides trials were halted because they led to more HIV infections instead of less . In 2009, vaccine researchers reported some success in a trial in Thailand, but the observed vaccine efficacy was too modest to be of any public health significance . In 2010, microbicide researchers reported a first success in a trial in South Africa. Women who used the, to be tested microbicide were 39 percent less likely to become infected with HIV than women who received a placebo gel . However, the consequences of these recent findings for prevention schemes are not clear yet and currently under discussion. Consequently, these technologies still are being researched and have not yet been applied in HIV prevention programmes. This means that the funding directed to this category of HIV preventives totally goes to research rather than to application in HIV prevention programmes, and therefore has not yet a direct effect on prevention.
Another HIV prevention technology is condoms and integrated condom programming. In contrast to vaccines and microbicides, male condoms have existed since at least 1000 BC. Female condoms, which are as effective as male condoms, have existed since 1984, and were officially approved by the United States Food and Drug Administration (US FDA) in 1993 [17, 18]. In 2009, UNAIDS, WHO and UNFPA renewed their joint position statement on condoms: "The latex condom is the single, most efficient, available technology to reduce the sexual transmission of HIV" . Empirically, its cost-effectiveness in comparison to other HIV prevention methods has been proven [20, 21]. Female and male condoms are central to efforts to halt the spread of HIV. This was officially recognized as early as 1994 in the Programme of Action of the International Conference on Population and Development ; again in 2001 in the Political Declaration of commitment on HIV/AIDS in the United Nations General Assembly Special Session (UNGASS) on HIV/AIDS ; and again in 2005 as part of a plan to achieve the Millennium Development Goals . The female condom in particular is currently the only technology that gives women greater control over protecting themselves from HIV, other STIs and unintended pregnancy [25, 26].
Integrated condom programming is essential to the realisation of sexual and reproductive health and rights, including the prevention of HIV [27–29]. Integrated means that the programme is delivering two or more types of services previously provided separately, as a single, coordinated, and combined service. Examples are condom programming combined with counselling services on family planning, or with HIV/STI testing services or with sexuality education . Integrated condom programming has proven to be successful, under the condition that a gender, relational and community perspective is used [31, 32]. And that the condoms are affordable. Cost studies have shown that the consumer price of condoms has a strong effect on access and, thus, usage . Integrated programmes, which subsidise or freely distribute condoms, have led to increased usage, a condition for effectiveness in HIV prevention . In July 2010, during the last international AIDS conference in Vienna, UNAIDS reported on successes in HIV prevention by integrated condom programming in a multi country study . At the same conference, a researcher from John Hopkins University showed convincing results of declining HIV infection rates in countries with generalised HIV epidemics. These declines occurred in a time when antiretroviral treatments were not yet available and when priority was on prevention through sexual behavioural change programmes combined with unproblematic access to condoms . It is beyond the scope of this article to discuss the factors leading to successful condom programming in-depth. However, it is important to recognise that it is an evidence-based, cost-effective, efficient, and directly available way of delivering HIV prevention services to people.
Apart from the two above mentioned prevention approaches, three other HIV prevention technologies were introduced in some developing countries such as male circumcision , use of anti-retroviral drugs in pregnancy to prevent mother to child transmission (PMCT) , or prophylactic use of antiretroviral drugs (PreP) . All three technologies will only be partly efficacious for preventing sexual transmission of HIV. Circumcised men may still contract HIV (and other STI's), and can still pass it on to their next partner, making protection with condoms still necessary and thus, the need for integrated condom programming. The need for protection also remains when introducing PMCT or PreP. There is still much discussion on the assessment of the effectiveness of the various HIV prevention technologies. The assessment varies with the researchers' disciplinary perspective. Kippax concluded in her study that the (bio-) medical sciences are dominant in the discussion on HIV prevention, leaving hardly any space for social sciences . In this article, we will not address the different scientific interpretations in HIV prevention effectiveness, since this is done recently by Heise et al . We will focus on the funding choices being made in HIV prevention. Our first question is therefore: How is the public funding from USA and Europe for HIV prevention divided over research on HIV preventive vaccines and microbicides and integrated condom programming in the period 2000 to 2008?
We are particularly interested in the funding choices in HIV prevention, taken by two different public donors, the USA government, and European governments, including the EU. The European public donors have a long tradition of supporting gender and sexual and reproductive health and rights as part of Official Development Aid [42, 43]. The following statement on HIV prevention of the Council of the European Union illustrates its position:
We re-affirm our commitment to tackle the HIV pandemic in a comprehensive and integrated way and in particular the HIV prevention gap. We are profoundly concerned about the resurgence of partial or incomplete messages on HIV prevention, which are not grounded in evidence and have limited effectiveness. We, the European Union, firmly believe that HIV prevention must utilise all approaches known to be effective, like universal access to sexual and reproductive health information in accordance with the international decisions at the International Conference on Population and Development agenda and reliable access to essential sexual and reproductive health commodities, including male and female condoms .
The European donors thus clearly recognise the importance of sexual and reproductive health and rights, and explicitly state the necessity to provide reliable access to male and female condoms. In contrast, the USA government failed to set up a holistic sexual and reproductive health and rights approach in development aid. In the period between 2000 and 2008, especially with the Bush presidency, it has implemented a conservative HIV policy leading to a global anti-condom movement [45, 46], started earlier by the Catholic Church. Because of this difference in policy, we expect to find that the European governments and the EU give a larger share of the funding to integrated condom programming in the period 2000 - 2008 than the USA. Our second question therefore is: Is there a difference in public donor funding within HIV prevention between the EU and the USA?