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PEPFAR cuts may cost 9m years of lost life in SA and Ivory Coast

US President Donald Trump’s plan to cut foreign aid supporting HIV/Aids treatment could cost 9m years of lost life in South Africa and Ivory Coast, according to a US study.

Eyewitness News reports that in the first study to measure the impact of cuts in global investment in HIV care in terms of health and costs, scientists found sky-rocketing deaths in the African nations would far outweigh savings.

South Africa has the highest prevalence of HIV worldwide, with 19% of its adult population carrying the virus in 2015, according to UNAIDS, with a total of 7m HIV-infected people. Ivory Coast counted 460,000 HIV-infected people in that same year.

The report says Trump’s proposed budget for 2018, made public in May, envisions cuts to the President’s Emergency Plan for Aids Relief (PEPFAR) programme, a cornerstone of US global health assistance, which supports HIV/Aids treatment, testing and counselling for millions of people worldwide.

Under Trump’s budget, which pursues his “America First” world view, PEPFAR funding would be $5bn per year compared to about $6bn annually now, the US State Department has said. No patient currently receiving antiretroviral therapy, a treatment for HIV, through PEPFAR funds will lose that treatment, officials have said.

The report says should the cuts keep South Africans and Ivorians from receiving antiretroviral drugs, an additional 1.8m HIV-infected people would die over the next 10 years, 11 researchers in America, Europe and Africa concluded, using mathematical models. The combined deaths amount to nearly 9m years of life lost, the scientists calculated, in what they said was the first effort to put figures on the proposed cuts.

The researchers measured expected savings over the next decade, whose small scale they said raised efficacy and ethical questions. In South Africa, it would amount to some $900 per year of life lost, compared to $600 to $900 in Ivory Coast. “We leave it to readers to draw their own conclusions about whether imposing such trade-offs on vulnerable populations accurately reflects how donor countries value life in recipient nations,” the report says the researchers wrote.

Savings would eventually dry up over the decade, they found, due to higher costs tied to the spread of HIV amid scaled back screening and care. “Would the relatively small savings realised by currently proposed budget reductions be worth these large humanitarian costs?” said lead author Rochelle Walensky, a professor of medicine at Harvard Medical School.

“Over the past decade and a half we’ve spent considerable money to save lives in these and other African nations.” Some 90% of Ivory Coast’s funding for HIV care and prevention depends on international aid, while South Africa self-finances most of its HIV expenditures, according to US government figures.

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 applying the least harmful and most efficient alternatives for achieving budget cuts of 10% to 20%, 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.

Rochelle P Walensky; Ethan D Borre; Linda-Gail Bekker; Emily P Hyle; Gregg S Gonsalves; Robin Wood; Serge P Eholié; Milton C Weinstein; Xavier Anglaret; Kenneth A Freedberg; A David Paltiel

[link url=""]Eyewitness News report[/link]
[link url=""]Annals of Internal Medicine abstract[/link]

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