Do Less Harm: Evaluating HIV Programmatic Alternatives in Response to Cutbacks in Foreign Aid

Background:

Resource-limited nations must consider their response to potential contractions in international support for HIV programs.

Objective:

To evaluate the clinical, epidemiologic, and budgetary consequences of alternative HIV program scale-back strategies in 2 recipient nations, the Republic of South Africa (RSA) and Côte d'Ivoire (CI).

Design:

Model-based comparison between current standard (CD4 count at presentation of 0.260 × 10⁹ cells/L, universal antiretroviral therapy [ART] eligibility, and 5-year retention rate of 84%) and scale-back alternatives, including reduced HIV detection, no ART or delayed initiation (when CD4 count is <0.350 × 10⁹ cells/L), reduced investment in retention, and no viral load monitoring or second-line ART.

Data Sources:

Published RSA- and CI-specific estimates of the HIV care continuum, ART efficacy, and HIV-related costs.

Target Population:

HIV-infected persons, including future incident cases.

Time Horizon:

5 and 10 years.

Perspective:

Modified societal perspective, excluding time and productivity costs.

Outcome Measures:

HIV transmissions and deaths, years of life, and budgetary outlays (2015 U.S. dollars).

Results of Base-Case Analysis:

At 10 years, scale-back strategies increase projected HIV transmissions by 0.5% to 19.4% and deaths by 0.6% to 39.1%. Strategies can produce budgetary savings of up to 30% but no more. Compared with the current standard, nearly every scale-back strategy produces proportionally more HIV deaths (and transmissions, in RSA) than savings. When the least harmful and most efficient alternatives for achieving budget cuts of 10% to 20% are applied, every year of life lost will save roughly $900 in HIV-related outlays in RSA and $600 to $900 in CI.

Results of Sensitivity Analysis:

Scale-back programs, when combined, may result in clinical and budgetary synergies and offsets.

Limitation:

The magnitude and details of budget cuts are not yet known, nor is the degree to which other international partners might step in to restore budget shortfalls.

Conclusion:

Scaling back international aid to HIV programs will have severe adverse clinical consequences; for similar economic savings, certain programmatic scale-back choices result in less harm than others.

Primary Funding Source:

National Institutes of Health and Steve and Deborah Gorlin MGH Research Scholars Award.

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