Saving money, losing lives

Analysis by David Paltiel, professor at Yale School of Public Health and a visiting professor at the Laboratory for Interdisciplinary Evaluation of Public Policies (LIEPP) at Sciences Po.

Recent cutbacks in global funding for HIV/AIDS force donor nations to confront how little they are willing to give up to save a life on another continent. For the last two decades, global assistance programmes have enjoyed robust support and remarkable success in providing HIV/AIDS prevention and treatment services in resource-limited settings.
Recently, however, there are signs of funder fatigue and mounting political resistance. In 2016, for example, donor government funding to support HIV efforts in low- and middle-income countries decreased for the second consecutive year, from US$7.5 billion to US$7 billion. The Global Fund to Fight AIDS, Tuberculosis and Malaria has scaled back the number of funding-eligible nations it serves. Most recently, the White House proposed a 33% cut to the US foreign aid budget, jeopardizing more than US$6.7 billion currently earmarked for HIV/AIDS prevention, care, and research.
 
These developments raise important questions for donor and recipient nations alike: What are the likely health and economic effects of reduced global investment in HIV prevention and care? How much money can be saved while maintaining existing commitments? What cost-containment options are available, how much will each option save, and what harms will it create?
 
Working with colleagues in Côte d’Ivoire and the Republic of South Africa, we addressed these questions using a mathematical simulation and publicly available data. Here, we highlight four key findings:

The economic savings will be small and short-lived

Given existing commitments to persons already receiving care for HIV infection, savings greater than 30% of current outlays are unlikely. Moreover, most of the savings will dry up with time, as the downstream costs of patient neglect and failure to reduce HIV transmission accumulate.

The health harms will be large and lasting

Whether the yardstick is mortality, life-expectancy, or new HIV transmissions, cutbacks will almost certainly produce proportionally greater harm than economic good. We estimate more than 500,000 additional HIV transmissions and 1.6 million more HIV-related deaths in South Africa over the next 10 years. In Côte d’Ivoire, HIV-related deaths could increase 35% over that period.

For recipient nations, there are better and worse responses to reduced foreign assistance. 

Policies that either delay the presentation of the healthiest patients to care or reduce investments in patient retention will do the least harm in terms of deaths, years of life lost and new HIV transmissions.

Even if recipient nations act optimally to minimize the harm to their citizens, each year of life lost in Africa due to cutbacks will save donors no more than $900.

This fourth finding – and the shocking humanitarian cost it imposes on vulnerable populations – should take your breath away. Evidence abounds that citizens of resource-rich nations, like the United States and France, will willingly pay upwards of $100,000 to save a single year of life. Does the imposition of this disparity – a year of life to save ourselves $900 – accurately reflect how we in donor countries value life in Africa?
 
Scale-back of international aid to HIV programs in resource-limited settings will reverse enormous progress made over the past 20 years in curbing HIV transmission and improving HIV-related outcomes. We have it in our power – and even within our economic reach – to stop the global AIDS epidemic in its tracks. Now is the time to redouble our efforts, not to cut back and witness the reversal of hard-earned successes.


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