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

Annals of Internal Medicine
7 November 2017 Vol: 167, Issue 9
http://annals.org/aim/issue

Do Less Harm: Evaluating HIV Programmatic Alternatives in Response to Cutbacks in Foreign Aid
Rochelle P. Walensky, MD, MPH; Ethan D. Borre, BA; Linda-Gail Bekker, MD, PhD; Emily P. Hyle, MD, MSc; Gregg S. Gonsalves, PhD; Robin Wood, MMed, DSc (Med); Serge P. Eholié, MD, MSc; Milton C. Weinstein, PhD; Xavier Anglaret, MD, PhD; Kenneth A. Freedberg, MD, MSc; A. David Paltiel, PhD, MBA
Abstract
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.