Planning and sustaining HIV response in the countries of the "risky middle"

This paper focusses on high-HIV middle-income countries termed the "risky middle", i.e. characterised by a typology based on HIV burden and gross national income (GNI), according to which seven countries - Lesotho, Eswatini, Kenya, Zimbabwe, Tanzania, Namibia and Zambia - are identified. There is particular concern for "people left behind", the factors determining a country's ability to mobilise resources in the context of multiple development needs - including economic disparities; the political economy of fiscal decision-making; levels of health investment; health and community systems; political will; and currency fluctuations. While donors will support lower-income countries and higher-income countries can compensate from domestic resources, there is a risk that some high-burden, lower middle-income countries will be unable to sustain a response. Continued growth means that there are countries transitioning to higher World Bank income classification - an important criterion for allocating development assistance for health. Our concern is that countries may face external funding reduction once their income category improves, and those in the risky middle will be unable to compensate from domestic resources. We conclude, with guidance from UNAIDS, the international community should step up support for "risky middle" countries. In addition these countries need to recognise the threat and develop measures to counter it, including improved accountability. Funding declines should be reversed through funding benchmarks that relate to both GDP and HIV prevalence. Finally, risky middle countries could constitute themselves as a special interest group, to protect their HIV funding and AIDS response.