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HIV SIB drives policy change

Elton John Aids Foundation Zero HIV SIB drives policy change

The Zero HIV SIB brought together Lambeth Council, The National Lottery Community Fund, ViiV Healthcare, Comic Relief, and Big Issue together with our client the Elton John AIDS Foundation (EJAF) to deliver the first Social Impact Bond (SIB) focussed on HIV diagnosis and treatment.

Since the Zero HIV SIB has recently drawn to a close we look at what makes this SIB unique, its impact on policy and its contribution to an end to HIV transmission in England by 2030.

Programme design

We began advising EJAF in 2017 on the development of a SIB (for further information on Freshfields’ experience in, and a description of, this product see our case study here). The SIB was designed to reach individuals with undiagnosed HIV, or previously diagnosed HIV but whose treatment had lapsed, and bring them into treatment. Treatment is a powerful tool in the fight against HIV since, not only does it enable the recipient to live a long and healthy life, it also effectively prevents transmission and avoids expensive NHS treatment when people become seriously unwell with AIDS defining illnesses. The Zero HIV SIB was based in the South London boroughs of Lambeth, Southwark, and Lewisham due to their disproportionately high HIV prevalence, with an estimated 1,000 residents living with HIV that are unaware of their status in these boroughs.

To reach patients the SIB relied on hospitals, GP surgeries and community organisations (the “delivery providers”). Each of these providers delivered a different type of intervention and was incentivised to do so by being paid for each individual who undertook an HIV test and was diagnosed with HIV, or was re-engaged in treatment; these results were called an “outcome”. Emergency Departments and GP practices implemented opt-out HIV testing whenever blood was taken,  community organisations implemented targeted testing for high-risk populations, and HIV clinics and primary care implemented recall systems to re-engage known HIV patients no longer receiving care and bring them back into treatment. 

EJAF established a Community Interest Company (CIC) to hold the contract with the commissioner Lambeth Council and subcontract with the delivery providers.  While all payments to providers  were made on an “outcomes” basis, the CIC pre-funded a proportion of the outcomes to allow the delivery providers to carry out the testing and outreach programmes to deliver these outcomes. The outcomes were paid through Lambeth Council, who made a small contribution to the costs of the outcomes, with the balance being funded by EJAF, helped by a generous contribution of over £1 million through the National Lottery Community Fund’s Commissioning Better Outcomes programme. It had not been the intention for EJAF to act as outcome payer, but due to constraints in NHS and local authority budgets EJAF decided to fund outcomes on the basis that if the evidence was strong enough the health care system would fund in the future.

EJAF invested in the SIB alongside Big Issue Invest, Comic Relief and ViiV Healthcare UK Ltd. The CIC Board included representatives from the commissioner, Lambeth Council, from each of the investors, and was chaired by a Director from The Bridges Impact Foundation. The programme was steered by a Project Advisory Board which brought together representatives from the three local authorities and clinical commissioning groups with expertise in HIV commissioning and the community sector.  This enabled the SIB to be informed by on the ground HIV expertise, and benefit from local insight.

Freshfields assisted with the structuring of the SIB, including the establishment of the CIC and advised on all of the contracts between the parties involved (including both outcomes and delivery contracts as well as funding arrangements). We remained involved throughout, advising on additional contracts and amendments through which the SIB has been scaled up over time and, over the past two years, helping to make amendments required as a result of the impact of Covid on the settings in which the interventions would be delivered.


Over the three years of the SIB’s operation (2018-2021), 209 people were newly diagnosed with HIV and engaged into care.  A further 256 people were reengaged into HIV care, some of whom had stopped treatment many years ago.  EJAF have modelled that the savings (costs avoided) to the health system are over £220,000 per person living with HIV linked to care. The SIB showed that the average costs of finding someone with a new diagnosis was less than £10,000, and reengaging someone was less than £4,000. The costs avoided to the health care system of these 465 outcomes are therefore estimated to be in excess of £90 million. Further details of the results of the SIB can be found here.

Impact on National Policy

The Zero HIV SIB enabled EJAF to gather the evidence of effective HIV testing and reengagement activities (including opt-out testing) required to influence the Department of Health and Social Care and the UK Health Security Agency. As a result of the influencing of EJAF and its campaigning partners, the government launched the HIV Action Plan in December 2021, which took on board the importance of these interventions in the battle to achieve zero HIV transmissions and included a £20 million commitment to Emergency Department HIV testing.  

This means that those living with undiagnosed HIV or who have stopped HIV treatment stand a much better chance of being diagnosed and receiving the treatment that they need to live healthy and long lives. This in turn should also result in a reduction of HIV transmission and an avoidance of large costs to the health care system. 

Elton John, Founder of the Elton John AIDS Foundation said: ‘Today’s news of the UK Government’s commitment to provide £20 million to opt-out HIV testing underscores how critical the Elton John AIDS Foundation’s Social Impact Bond in south London has been over the past three years and we’re proud that this life-saving work for vulnerable communities will continue across the country.’

Next steps

We are now working with the Elton John AIDS Foundation to take this innovating funding model to the US where similar funding models (there called Pay-for-Success or Outcomes-Based-Financing) have significant momentum, but have not yet focussed on HIV treatment. Similar to the UK SIB, we see an opportunity in the US to develop a meaningful programme with measurable health outcomes, health system savings, and ultimately, systemic policy change.