Reductions in U.S. foreign aid for HIV programs may result in small cost savings but severe clinical consequences

1. Reducing U.S. foreign aid could produce severe negative clinical and epidemiological effects while saving only $900 or $600 to $900 per year of life lost in the Republic of South Africa (RSA) and Côte d’Ivoire (CI), respectively.

2. Eventually, any cost savings would be negated by the accruing costs of caring for the increased cases of patients with HIV resulting from downscale strategies.

Evidence Rating Level: 3 (Average)

Study Rundown: The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) has assisted resource-limited countries in HIV prevention efforts and in providing antiretroviral treatment (ART). However, the U.S. government is considering reducing U.S. foreign aid by more than $6.7 billion. This study seeks to estimate the clinical, epidemiological, and financial effects of budget cuts in RSA and CI. Using a mathematical model as well as epidemiological and cost data for RSA and CI, researchers compared various methods of downsizing testing, treatment, and monitoring for HIV. Each method was compared to a current standard benchmark. The target population were HIV-infected individuals ≥15 years old beginning in 2016 and continuing for a total of 10 annual cohorts. Outcome measures included the financial savings of each strategy, how many additional infections and deaths would occur, and the number of added years of life lost. The authors concluded that reducing aid would produce severe negative clinical and epidemiological effects and that any cost savings would eventually be negated by the accruing costs of caring for the increased cases of patients with HIV resulting from downscale strategies.

A strength of the study includes a 10-year projection using a well-published mathematical model and published RSA- and CI-specific estimates of HIV-related costs, ART efficacy, and HIV care.

Limitations of the study include the unknown size and details of the actual budget cuts and the unknown degree to which foreign aid sources outside the U.S. may offset any budget cuts.

Click to read the study, published in the Annals of Internal Medicine

Relevant Reading: PEPFAR in transition — Implications for HIV care in South Africa

In-Depth [mathematical model]: To study various HIV program downscaling methods, researchers used the Cost-Effectiveness of Preventing AIDS Complications–International (CEPAC-I) model, which simulates the progression and treatment of HIV disease in settings with limited resources. The scale-back strategies studied included reserving ART for only the most ill patients, reducing HIV testing, decreasing retention of patients in care, eliminating viral load (VL) testing, and eliminating second-line therapy for those who fail to respond to first-line ART. Researchers estimate that at 10 years, downscaling methods will raise HIV transmissions and deaths in RSA by 0.5% to 19.4% (630 000) and 0.6% to 39.1% (1.664 million), respectively. In CI, HIV transmissions and deaths could increase by as much as 10.5% (24 000) and 34.6% (93 000), respectively. In comparison to the current standard, nearly all methods result in proportionally higher HIV deaths than savings. Even when using the downscaling method that is most efficient and the least damaging to accommodate a 10% to 20% budget cut, only $900 will be saved in RSA and $600 to $900 in CI per year of life lost.

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