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Abstract
The United States’ President’s Emergency Plan for AIDS Relief (PEPFAR) has provided technical and financial support to the most burdened low- and middle-income countries (LMICs) for over 20 years, leading to gains toward HIV epidemic control. As global donor priorities shift, and more LMICs seek to assume control of their national HIV programs, there is an increased need to identify structural opportunities to sustain these gains. While the literature has suggested a relationship between government decentralization and individual- and population-level HIV outcomes in LMICs, its direction is unclear, and little is known about the effect of global donor programs on this relationship.
This ecological, cross-national study employed an ordinary least squares regression model and a panel regression model (2010-2019) to explore the relationship between fiscal decentralization, reduction in HIV incidence, and three HIV treatment cascade outcomes in 96 LMICs. Results indicate that LMICs with PEPFAR programs were more effective at controlling their HIV epidemics than those without, and higher degrees of fiscal decentralization were associated with reduced HIV incidence (2019-2010), increased awareness of personal HIV status, and increased participation in anti-retroviral therapy (ART). PEPFAR did not appear to have a moderating effect on the relationship between the three HIV treatment cascade variables and fiscal decentralization, though it may moderate the relationship between 1) fiscal decentralization and reductions in HIV incidence and 2) political decentralization and the percentage of people living with HIV receiving ART. PEPFAR programs appear more successful in countries with lower degrees of political decentralization and higher degrees of fiscal decentralization. Fiscal decentralization may help LMICs reach HIV epidemic control through reduced incidence and achievement of the HIV treatment cascade 95-95-95 goals. Countries seeking to take over their national HIV programs and sustain PEPFAR progress should identify and leverage opportunities to better align HIV policies and practices with decentralization policies and institutions.
This ecological, cross-national study employed an ordinary least squares regression model and a panel regression model (2010-2019) to explore the relationship between fiscal decentralization, reduction in HIV incidence, and three HIV treatment cascade outcomes in 96 LMICs. Results indicate that LMICs with PEPFAR programs were more effective at controlling their HIV epidemics than those without, and higher degrees of fiscal decentralization were associated with reduced HIV incidence (2019-2010), increased awareness of personal HIV status, and increased participation in anti-retroviral therapy (ART). PEPFAR did not appear to have a moderating effect on the relationship between the three HIV treatment cascade variables and fiscal decentralization, though it may moderate the relationship between 1) fiscal decentralization and reductions in HIV incidence and 2) political decentralization and the percentage of people living with HIV receiving ART. PEPFAR programs appear more successful in countries with lower degrees of political decentralization and higher degrees of fiscal decentralization. Fiscal decentralization may help LMICs reach HIV epidemic control through reduced incidence and achievement of the HIV treatment cascade 95-95-95 goals. Countries seeking to take over their national HIV programs and sustain PEPFAR progress should identify and leverage opportunities to better align HIV policies and practices with decentralization policies and institutions.