Proposed reductions in U.S. foreign aid would have a devastating impact on HIV treatment and prevention programs in countries receiving such aid, an international team of investigators reports. In their paper published online in Annals of Internal Medicine, the team led by researchers at Massachusetts General Hospital (MGH) and the Yale School of Public Health describes how a 33 percent cutback in funds earmarked for HIV/AIDS prevention, treatment and research in recent budget proposals would only save $900 per year of life lost in the countries of South Africa and Côte d’Ivoire.

“This study is the first to document the health and economic returns of a reduced global investment in HIV prevention and care,” says lead and corresponding author Rochelle P. Walensky, MD, MPH, of the MGH Division of Infectious Diseases. “Over the past decade and a half we’ve spent considerable money to save lives in these and other African nations. Would the relatively small savings realized by currently proposed budget reductions be worth these large humanitarian costs?”

She and her colleagues note that, since the late 1990s, global HIV prevention and treatment initiatives in resource-limited settings have enjoyed robust support and remarkable success. But recently funding has plateaued, suggesting both donor fatigue and mounting political resistance to continuing the scale-up of these programs.

In order to project the impact of proposed cutbacks to U.S.-funded programs in South Africa, which has the greatest prevalence of HIV infection of any country, and the west African nation of Côte d’Ivoire, which has a different kind of epidemic and a different level of foreign aid dependency, the researchers used a widely-published mathematical model along with epidemiologic and cost data from each country to project the outcomes of potential programmatic responses. These include scaling back HIV screening activities, restricting access to antiretroviral therapies to only the sickest patients, eliminating backup treatment strategies for patients who do not respond to initial therapies, minimizing laboratory monitoring of diagnosed patients and decreasing efforts to retain patients in care. Among their considerations were how much money could be saved by each strategy, how many new infections and deaths would occur, and how many additional years of life would be lost.

The results revealed that the savings are likely to be small and transient. Existing commitments to patients already receiving care for HIV infection would restrict overall saving to no more than 30 percent. Over time, those saving would dry up as the increase in HIV transmissions would lead to accumulating costs for the care of those patients. In contrast, the epidemiological consequences would be large and lasting. In South Africa alone, cutbacks could result in more than 500,000 additional cases of HIV and more than 1.6 million more deaths over the next 10 years.

Study co-author Linda-Gail Bekker, MD, PhD – Desmond Tutu HIV Centre, University of Cape Town, South Africa, and current President of the International AIDS Society – says, “Whether the yardstick is mortality, life expectancy or new transmissions, these reductions would almost certainly produce proportionally greater harm than savings – do more human harm than economic good.”

In Côte d’Ivoire, HIV-related deaths could be as much as 35 percent higher if the cutbacks were implemented. Co-author Xavier Anglaret, MD, PhD – University of Bordeaux, INSERM and PAC-CI Programme, Côte d’Ivoire – says, “Given the extraordinary investments and progress made to date, now is the time to redouble our efforts, not to cut back and witness the reversal of hard-earned successes.”

The study is also the first to consider how recipient nations might tailor their response to impending cutbacks. In South Africa, the researchers found that, for any given level of budget cutting, policies that delay the presentation of the healthiest patients to care would do the least harm in terms of deaths, years of life lost and new HIV transmissions. In Côte d’Ivoire, the optimal policy would be to reduce investments in patient retention.

Walensky, a professor of Medicine at Harvard Medical School and the Steve and Deborah Gorlin Research Scholar at MGH, says, “There are better and worse choices within this set of bad alternatives.  This study provides critical information, on a nation-by-nation basis, about how to best implement potential cuts to minimize suffering.”

The researchers are quick to caution that they are neither endorsing any of these painful choices nor excusing the political decisions that may make them necessary. Senior author A. David Paltiel, MBA, PhD, professor of Public Health (Health Policy) at the Yale School of Public Health, says, “Our aim is to confront donor nations with the clinical and economic consequences of any decision to substantially cut HIV program funding and to help recipient nations respond in the least harmful ways possible to the actions of countries in the developed world.”

Additional co-authors of the report are Ethan Borre, Emily P. Hyle, MD, MSc, and Kenneth A. Freedberg MD, MSc, MGH Medical Practice Evaluation Center; Robin Wood, FCP, MMed, DSc, University of Cape Town; Gregg Gonsalves, PhD, Yale School of Public Health; Serge P. Eholie, Trecheville University Hospital, Abidjan, Côte d’Ivoire; and Milton Weinstein, PhD, Harvard T.H. Chan School of Public Health. The study was supported by grants from the National Institutes of Health and the Steve and Deborah Gorlin MGH Research Scholars Award.

The Yale School of Public Health was founded in 1915 and is one of the oldest accredited schools of its kind in the United States. Today the school has nearly 250 full- and part-time faculty who conduct a wide range of research around the world to addresses current health problems as well as emerging diseases. The school also has some 4,500 alumni who work in 70 countries and in virtually every field of public health. Through its collaborative approach to research, education and training, the Yale School of Public Health has fostered meaningful innovations that have improved the health and well-being of communities throughout the world.

Massachusetts General Hospital, founded in 1811, is the original and largest teaching hospital of Harvard Medical School. The MGH Research Institute conducts the largest hospital-based research program in the nation, with an annual research budget of more than $800 million and major research centers in HIV/AIDS, cardiovascular research, cancer, computational and integrative biology, cutaneous biology, genomic medicine, medical imaging, neurodegenerative disorders, regenerative medicine, reproductive biology, systems biology, photomedicine and transplantation biology. The MGH topped the 2015 Nature Index list of health care organizations publishing in leading scientific journals and earned the prestigious 2015 Foster G. McGaw Prize for Excellence in Community Service. In August 2017 the MGH was once again named to the Honor Roll in the U.S. News & World Report list of "America's Best Hospitals."