Implications of the Proposed Budget Cuts for HIV Programs 

[Trump cuts will hurt those affected with HIV/AIDS] 

Carlos del Rio, MD reviewing  Walensky RP et al.  Ann Intern Med 2017 Aug 29. 

Cuts in PEPFAR funding would result in an increased number of HIV transmissions and deaths in heavily affected countries.

Unprecedented success in the global response to HIV has been achieved as a result of substantial increases in resources for programs such as the U.S. President's Emergency Plan for AIDS Relief (PEPFAR). Close to 20 million people are now receiving antiretroviral therapy, and both mortality and new infections are in decline. Nevertheless, additional resources plus optimization of available funding will be needed to reach the UNAIDS 90-90-90 goals, so that by 2020, 90% of persons HIV will know their HIV status, 90% of persons with HIV will receive sustained antiretroviral treatment (ART), and 90% of persons receiving ART will achieve virologic suppression.

However, in its current budget, the Trump administration proposes cutting foreign aid by a third, which would affect some $6.7 billion for programs focused on HIV/AIDS, including PEPFAR, the Global Fund, CDC, and USAID. Now, investigators have used the Cost-Effectiveness of Preventing AIDS Complications-International (CEPAC-I) model to estimate the impact of such resource contraction in South Africa and Ivory Coast.

During the next decade, under current conditions, 3.24 million new HIV infections and 4.26 million HIV-related deaths are projected to occur in South Africa, and 225,000 new HIV infections and 270,000 HIV-related deaths are projected in the Ivory Coast. When the authors considered a menu of possible scale-back strategies, they estimated that an increase of 0.5% to 19.4% new HIV infections and an increase of 0.6% to 39.1% deaths would occur. None of the scale-back strategies resulted in more than a 30% decrease in savings, largely due to commitments to patients already in care and on ART. Moreover, any cost savings in the short-term most often resulted in higher costs later, due to increased HIV transmissions.

Faced with the selection of difficult alternatives, the authors identified strategies that delay presentation to care (in South Africa) and reduce retention (in the Ivory Coast) as those that might generate the least harm for the most savings. The scale-back strategies that maximize efficiencies and minimize harm would lead to no more than $900 saved in domestic spending for each year of life lost in recipient nations.

1. Walensky RP et al. Do less harm: Evaluating HIV programmatic alternatives in response to cutbacks in foreign aid. Ann Intern Med 2017 Aug 29; [e-pub]. (https://www.ncbi.nlm.nih.gov/pubmed/28847013)