Study finds small savings, high costs in both dollars and lives from global HIV funding cuts

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“We leave it to readers to draw their own conclusions about whether imposing such tradeoffs on vulnerable populations accurately reflects how donor countries value life in recipient nations . . .” Walensky et al, Annals of Internal Medicine, August 28, 2017

Cutbacks to HIV services driven by diminishing donor dollars would result in reductions of no more than 30 percent of current spending, while inflicting individual and public health costs out of any proportion to the amounts of money saved, a study published in the Annals of Internal Medicine found.

Researchers, led by Dr. Rochelle Walensky of Massachusetts General Hospital Division of Infectious Disease, used funding as well as HIV service-related data from South Africa and the West African nation Côte d’Ivoire, two countries with different factors driving the spread of disease and donor funding.

“Scale-back” strategies doing the least harm in South Africa, the authors write, include delaying care for HIV by limiting opportunities to be diagnosed with the virus, cutting current spending on measures to retain patients by keeping services accessible and adapted to patients needs, and, finally, the measure that would bring the largest immediate cost savings while representing a retreat to the failed and destructive approach of a decade and a half ago  of no new initiations of the antiretroviral treatment that prevents HIV transmissions and illnesses, and offers the chance of near normal life expectancies. Those measures would save from 13 percent to 24 percent of current spending over the next 10 years — or the researchers calculated, about $900 for every year of life lost as a result of those reductions in services.

Other options weighed in the face of continued cuts in donor funding could include reverting to guidelines since debunked by science that made treatment eligibility dependent on measures of immune system damage, not monitoring patients’ viral loads and risking unnoticed treatment failure and resistance, and eliminating access to second-line antiretroviral treatment for patients whose virus is resistant to first lines of treatment. All would result in preventable deaths, illnesses, transmissions of the virus, and larger costs to health systems over time.

“We leave it to readers to draw their own conclusions about whether imposing such tradeoffs on vulnerable populations accurately reflects how donor countries value life in recipient nations,” the authors added.

The results of cutbacks could be even more destructive than the findings in this study, the researchers note, because their calculations did not include the coming “youth bulge” over the next two decades when the numbers of young people at greatest risk of HIV exposure and infection will increase dramatically.

In contrast to the humanitarian successes, public health and development advances and dividends in diplomatic goodwill celebrated by bipartisan leaders and policy makers since the advent of meaningful and focused investments in global HIV responses, the authors present a bleak scenario.

“Our findings suggest that reduced HIV foreign aid will produce a modest savings to donors at the expense of HIV epidemic revival and massive loss of life among recipient nations,” the authors conclude. “Should these cutbacks materialize, in-country policymakers will be forced to confront profound ethical dilemmas in allocating remaining resources while minimizing — although not entirely avoiding — harm to individuals and communities.”

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