August 28, 2017
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Proposed reductions in foreign aid for HIV place millions at risk

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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.