Perspective

Cuts in foreign aid for HIV place millions at risk

Cutbacks in international funds for HIV/AIDS prevention, treatment and research programs would save insignificant amounts of money and cause a devastating clinical and epidemiological impact, according to research published in Annals of Internal Medicine.

“During the late 1990s and early 2000s, global HIV programs enjoyed robust support and success in providing ART and HIV prevention activities to resource-limited settings,” Rochelle P. Walensky, MD, MPH, from Massachusetts General Hospital, and colleagues wrote. “In the past decade, however, funding has plateaued, suggesting donor fatigue and mounting political resistance worldwide ... Most recently, the U.S. government proposed cutting the U.S. foreign aid budget by one-third, affecting more than $6.7 billion currently earmarked for HIV/AIDS prevention, care and research.”

Walensky and colleagues sought to assess the clinical, epidemiologic and budgetary impact of alternative HIV program scale-back strategies in the Republic of South Africa and Côte d’Ivoire using the Cost-Effectiveness of Preventing AIDS Complications–International model. They compared the current standard described as CD4 count at presentation of 0.260 × 10 cells/L, universal ART eligibility and 5-year retention rate of 84% with alternative approaches to scaling back, including decreased HIV screening, no ART or delayed initiation when the CD4 count is less than 0.350 × 10 cells/L, reduced retention and no viral-load testing or second-line ART. They also evaluated published estimates of the HIV care continuum, ART efficacy and HIV-related costs for each country.

Results indicated that after 10 years, both projected HIV transmissions (ranging from 0.5% to 19.4%) and deaths (ranging from 0.6% to 39.1%) increased because of scale-back strategies. More than 500,000 additional cases of HIV and more than 1.6 million deaths could occur during the next 10 years in South Africa alone due to the cutbacks. Overall budgetary savings of up to 30% resulted from scaling back. In South Africa, approximately $900 in HIV-related outlays would be saved for every year of life lost, and in Côte d’Ivoire, about $600 to $900 would be saved when employing the least damaging and most effective scale-back alternatives for attaining budget cuts of 10% to 20%.

“To be clear, we are neither endorsing any of these painful choices nor excusing the political decisions that may make them necessary,” the researchers wrote. “But we show that assessing the clinical, epidemiologic and economic effects of alternative scale-back scenarios is possible and that some decisions made in response to the imposition of budget cuts will do less harm than others.” – by Alaina Tedesco

Disclosures: Walensky reports receiving grants from NIH and Massachusetts general Hospital. Please see study for all other authors’ relevant financial disclosures.

Cutbacks in international funds for HIV/AIDS prevention, treatment and research programs would save insignificant amounts of money and cause a devastating clinical and epidemiological impact, according to research published in Annals of Internal Medicine.

“During the late 1990s and early 2000s, global HIV programs enjoyed robust support and success in providing ART and HIV prevention activities to resource-limited settings,” Rochelle P. Walensky, MD, MPH, from Massachusetts General Hospital, and colleagues wrote. “In the past decade, however, funding has plateaued, suggesting donor fatigue and mounting political resistance worldwide ... Most recently, the U.S. government proposed cutting the U.S. foreign aid budget by one-third, affecting more than $6.7 billion currently earmarked for HIV/AIDS prevention, care and research.”

Walensky and colleagues sought to assess the clinical, epidemiologic and budgetary impact of alternative HIV program scale-back strategies in the Republic of South Africa and Côte d’Ivoire using the Cost-Effectiveness of Preventing AIDS Complications–International model. They compared the current standard described as CD4 count at presentation of 0.260 × 10 cells/L, universal ART eligibility and 5-year retention rate of 84% with alternative approaches to scaling back, including decreased HIV screening, no ART or delayed initiation when the CD4 count is less than 0.350 × 10 cells/L, reduced retention and no viral-load testing or second-line ART. They also evaluated published estimates of the HIV care continuum, ART efficacy and HIV-related costs for each country.

Results indicated that after 10 years, both projected HIV transmissions (ranging from 0.5% to 19.4%) and deaths (ranging from 0.6% to 39.1%) increased because of scale-back strategies. More than 500,000 additional cases of HIV and more than 1.6 million deaths could occur during the next 10 years in South Africa alone due to the cutbacks. Overall budgetary savings of up to 30% resulted from scaling back. In South Africa, approximately $900 in HIV-related outlays would be saved for every year of life lost, and in Côte d’Ivoire, about $600 to $900 would be saved when employing the least damaging and most effective scale-back alternatives for attaining budget cuts of 10% to 20%.

“To be clear, we are neither endorsing any of these painful choices nor excusing the political decisions that may make them necessary,” the researchers wrote. “But we show that assessing the clinical, epidemiologic and economic effects of alternative scale-back scenarios is possible and that some decisions made in response to the imposition of budget cuts will do less harm than others.” – by Alaina Tedesco

Disclosures: Walensky reports receiving grants from NIH and Massachusetts general Hospital. Please see study for all other authors’ relevant financial disclosures.

    Perspective
    Paul A Volberding

    Paul A Volberding

    The article by Walensky and colleagues is profoundly disturbing. The authors model a scenario in which HIV treatment programs in two African countries are scaled back to reduce cost. Under various strategies, monetary costs are reduced, but at the human cost of increased HIV transmission and deaths. Not surprising, but a terrible contrast to all we have achieved.

    Paul A. Volberding

    Programs to treat HIV in low- and middle-income countries (LMIC) have been strikingly effective. In the U.S., one of the main providers of funding for HIV treatment in LMIC, these programs have enjoyed wide support from the entire political spectrum, almost unheard of in any other large foreign-aid endeavor. Increasingly, many countries are sharing in the cost of HIV care and expanding care beyond HIV alone to include other health conditions, thus further improving health across the population.

    Despite this success, threats remain real. A rise in nationalism in the U.S. and other donor countries could well reduce funding for HIV care abroad. And, of course, scale-backs could be exacerbated by economic downturns. Modeling to devise the least harmful way to spend less on HIV care is important but must raise loud alarms. Rather than treating fewer infected persons, we should insist that programs expand. We can control this epidemic, but treatment is our primary weapon. It may be time for another generation of AIDS activists, including all of us who remember the dark early days. We must not let that despair return.

    Walensky and colleagues predict how countries may do less harm by adjusting treatment and other parameters as AIDS-associated foreign aid diminishes. But turning back the clock on 20 years of progress in international aid is going to be nothing short of tumultuous. Because guillotining support is a real possibility ($2 billion cuts for PEPFAR and $6 billion for NIH as a whole per President Trumps 2018 budget), this future-world glimpse is timely. The clinical implications of more untreated HIV go beyond a single disease, however: an AIDS primer famously reads like a medicine textbook. There are hallmark opportunistic infections a veritable rogues gallery of bacteria, viruses, fungi and parasites; but there are also AIDS-associated malignancies, such as lymphoma, Kaposi sarcoma and anogenital cancers. Add the metabolic, neurologic, cardiovascular and other complications from untreated HIV/AIDS, and the financial impact of morbidity (not just mortality) is substantial. The HIV-uninfected will also suffer because budgets for health infrastructure and personnel, waterborne disease, tuberculosis and malaria are cut. Beyond the number crunching and the clinical implications, it is the impact on social upheaval that will be the hardest to project and prepare for. As much as Walensky and colleagues estimates are chilling, they are conservative because they do not account for all these downstream effects. A second, global AIDS epidemic wave will also find a different world than the one in 1981 one where drug resistance, a younger African population, climate change and terrorism may ultimately result in more harm, unless funding levels are sustained and even increased.

    Peter Chin-Hong

    • Paul A Volberding, MD
    • Infectious Disease News Chief Medical Editor

    Disclosures: Disclosure: Volberding reports no relevant financial disclosures.