Gandhi AR, Bekker LG, Paltiel AD, Hyle EP, Ciaranello AL, Pillay Y, Freedberg KA, Neilan AM. Potential Clinical and Economic Impacts of Cutbacks in the President's Emergency Plan for AIDS Relief Program in South Africa : A Modeling Analysis.
Ann Intern Med 2025;
178:457-467. [PMID:
39932732 PMCID:
PMC11996594 DOI:
10.7326/annals-24-01104]
[Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/13/2025] Open
Abstract
BACKGROUND
Future U.S. congressional funding for the President's Emergency Plan for AIDS Relief (PEPFAR) program is uncertain.
OBJECTIVE
To evaluate the clinical and economic impacts of abruptly scaling back PEPFAR funding ($460 million) from South Africa's total HIV budget ($2.56 billion) in 2024.
DESIGN
Model-based analysis of 100%, 50%, and 0% PEPFAR funding with proportional decreases in HIV diagnosis rates (26.0, 24.3, 22.6 per 100 person-years [PY]), 1-year treatment engagement (people with HIV [PWH] receiving/initiating antiretroviral therapy: 92.2%/80.4%, 87.1%/76.0%, 82.0%/71.5%), and primary prevention (4.0%, 2.2%, 0.5% reduction in incidence with no programming [1.24 per 100 PY]).
DATA SOURCES
Published HIV care continuum; PEPFAR funding estimates.
TARGET POPULATION
South African adults (HIV prevalence, 16.2%; incidence, 0.32 per 100 PY).
TIME HORIZON
Lifetime.
PERSPECTIVE
Health care sector.
INTERVENTION
PEPFAR funded 100% (PEPFAR_100%), 50% (PEPFAR_50%), or 0% (PEPFAR_0%).
OUTCOME MEASURES
HIV infections, life expectancy, and lifetime costs (2023 U.S. dollars).
RESULTS OF BASE-CASE ANALYSIS
With current HIV programming (PEPFAR_100%), 1 190 000 new infections are projected over 10 years; life expectancy would be 61.42 years for PWH, with lifetime costs of $11 180 per PWH. Reduced PEPFAR funding (PEPFAR_50% and PEPFAR_0%) would add 286 000 and 565 000 new infections, respectively. PWH would lose 2.02 and 3.71 life-years with nominal lifetime cost reductions of $620 per PWH and $1140 per PWH that would be offset at the population level by more PWH requiring treatment for infection.
RESULTS OF SENSITIVITY ANALYSIS
Countries with similar HIV prevalence and greater reliance on PEPFAR funding could experience disproportionately higher incremental infections and survival losses.
LIMITATION
Budget fungibility and exact programmatic implications of reducing PEPFAR funding are unknown.
CONCLUSION
Abrupt PEPFAR cutbacks would have immediate and long-term detrimental effects on epidemiologic and clinical HIV outcomes in South Africa.
PRIMARY FUNDING SOURCE
National Institutes of Health.
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