In the JournalsPerspective

Proposed reductions 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 [antiretroviral therapy] 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.”

As the effect of HIV funding contraction is unknown, 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 as a result 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 the Republic of South Africa alone due to the cutbacks. Overall budgetary savings of up to 30% resulted from scaling back.In the Republic of 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%.

“We have shown that scale-back of international aid to HIV programs in resource-limited settings will reverse enormous strides made over the past 20 years in curbing the global HIV epidemic and improving HIV-related survival,” Walensky and colleagues concluded. “Our findings suggest that reduced HIV foreign aid will produce modest savings to donors at the expense of HIV epidemic revival and massive loss of life among recipient nations. Should these cutbacks materialize, in-country policymakers will be forced to confront profound ethical dilemmas in allocating remaining resources while minimizing — although not entirely avoiding — harm to individuals and communities. To be clear, we are neither endorsing any of these painful choices nor excusing the political decisions that may make them necessary. 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 full study for complete list of 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 [antiretroviral therapy] 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.”

As the effect of HIV funding contraction is unknown, 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 as a result 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 the Republic of South Africa alone due to the cutbacks. Overall budgetary savings of up to 30% resulted from scaling back.In the Republic of 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%.

“We have shown that scale-back of international aid to HIV programs in resource-limited settings will reverse enormous strides made over the past 20 years in curbing the global HIV epidemic and improving HIV-related survival,” Walensky and colleagues concluded. “Our findings suggest that reduced HIV foreign aid will produce modest savings to donors at the expense of HIV epidemic revival and massive loss of life among recipient nations. Should these cutbacks materialize, in-country policymakers will be forced to confront profound ethical dilemmas in allocating remaining resources while minimizing — although not entirely avoiding — harm to individuals and communities. To be clear, we are neither endorsing any of these painful choices nor excusing the political decisions that may make them necessary. 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 full study for complete list of all other authors’ relevant financial disclosures.

 

    Perspective
    Paul Volberding

    Paul Volberding

    The article in this issue of the Annals of Internal Medicine by Walensky and colleagues is profoundly disturbing. In their work, titled “Do less harm: Evaluating HIV programmatic alternatives in response to cutbacks in foreign aid,” 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.

    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.

    • Paul Volberding, MD
    • Vice chair of the department of medicine
      University of California, San Francisco

    Disclosures: Volberding reports no relevant financial disclosures.

    Perspective
    Peter Chin Hong

    Peter V. Chin-Hong

    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. As guillotining support is a real possibility ($2 billion cuts for PEPFAR and $6 billion for NIH as a whole per President Trump’s 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 rogue’s gallery of bacteria, viruses, fungi and parasites; but 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 as 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 Dr. Walensky’s 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 V. Chin-Hong, MD
    • Professor of medicine
      University of California, San Francisco

    Disclosures: Chin-Hong reports no relevant financial disclosures.