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
Note: Dr. Walensky had access to all of the data in the study and takes responsibility for the integrity of the data and accuracy of the data analysis.
Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Acknowledgment: The authors thank Alex Bulteel for his technical assistance.
Financial Support: By grants R01 AI058736, R37 AI093269, K01 HL123349, R01 MH105203, and R01 DA015612 from the National Institutes of Health and by the Steve and Deborah Gorlin MGH Research Scholars Award (Dr. Walensky).
Disclosures: Dr. Walensky reports grants from National Institutes of Health and Massachusetts General Hospital during the conduct of the study. Mr. Borre reports grants from the National Institutes of Health during the conduct of the study. Dr. Bekker reports personal fees from Janssen and Merck Sharp & Dohme outside the submitted work. Dr. Hyle reports grants from the National Institutes of Health during the conduct of the study and royalties from UpToDate outside the submitted work. Dr. Weinstein reports grants from Harvard University during the conduct of the study and personal fees from OptumInsight outside the submitted work. Dr. Paltiel reports grants from the National Institutes of Health during the conduct of the study. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M17-1358.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer and Johnson & Johnson.
Reproducible Research Statement:Study protocol: Model design and structure are available at www.massgeneral.org/mpec/cepac. Statistical code: Overview of statistical structure is available at www.massgeneral.org/mpec/cepac. For more information, contact Dr. Walensky (e-mail, email@example.com). Data set: All data came from published literature. For more details, see Table 1.
Requests for Single Reprints: Rochelle P. Walensky, MD, MPH, Medical Practice Evaluation Center, Massachusetts General Hospital, 50 Staniford Street, 9th Floor, Boston, MA 02114; e-mail, firstname.lastname@example.org.
Current Author Addresses: Drs. Walensky, Hyle, and Freedberg and Mr. Borre: Medical Practice Evaluation Center, Massachusetts General Hospital, 50 Staniford Street, 9th Floor, Boston, MA 02114.
Drs. Bekker and Wood: Desmond Tutu HIV Foundation, PO Box 13801, Mowbray 7705, Cape Town, South Africa.
Dr. Eholié: Centre Hospitalier Universitaire de Treichville, Abidjan 1, Côte d'Ivoire.
Drs. Gonsalves and Paltiel: Yale School of Public Health, 60 College Street, New Haven, CT 06510.
Dr. Anglaret: Programme PACCI, Centre Hospitalier Universitaire de Treichville, 18 BP 1954, Abidjan 18, Côte d'Ivoire.
Dr. Weinstein: Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA 02115.
Author Contributions: Conception and design: R.P. Walensky, E.D. Borre, G. Gonsalves, R. Wood, M.C. Weinstein, A.D. Paltiel.
Analysis and interpretation of the data: R.P. Walensky, E.D. Borre, L.G. Bekker, E.P. Hyle, M.C. Weinstein, A.D. Paltiel.
Drafting of the article: R.P. Walensky, E.D. Borre, G. Gonsalves, R. Wood, X. Anglaret, A.D. Paltiel.
Critical revision of the article for important intellectual content: R.P. Walensky, E.D. Borre, L.G. Bekker, E.P. Hyle, G. Gonsalves, S.P. Eholié, M.C. Weinstein, X. Anglaret, A.D. Paltiel.
Final approval of the article: R.P. Walensky, E.D. Borre, L.G. Bekker, E.P. Hyle, G. Gonsalves, R. Wood, S.P. Eholié, M.C. Weinstein, X. Anglaret, K.A. Freedberg, A.D. Paltiel.
Statistical expertise: M.C. Weinstein.
Obtaining of funding: R.P. Walensky, A.D. Paltiel.
Administrative, technical, or logistic support: R.P. Walensky, E.D. Borre.
Collection and assembly of data: R.P. Walensky, E.D. Borre.
Resource-limited nations must consider their response to potential contractions in international support for HIV programs.
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).
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.
Published RSA- and CI-specific estimates of the HIV care continuum, ART efficacy, and HIV-related costs.
HIV-infected persons, including future incident cases.
5 and 10 years.
Modified societal perspective, excluding time and productivity costs.
HIV transmissions and deaths, years of life, and budgetary outlays (2015 U.S. dollars).
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.
Scale-back programs, when combined, may result in clinical and budgetary synergies and offsets.
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.
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.
National Institutes of Health and Steve and Deborah Gorlin MGH Research Scholars Award.
Rochelle P. Walensky, Ethan D. Borre, Linda-Gail Bekker, Emily P. Hyle, Gregg S. Gonsalves, Robin Wood, et al. Do Less Harm: Evaluating HIV Programmatic Alternatives in Response to Cutbacks in Foreign Aid. Ann Intern Med. 2017;167:618–629. doi: 10.7326/M17-1358
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Published: Ann Intern Med. 2017;167(9):618-629.
Published at www.annals.org on 29 August 2017
HIV, Infectious Disease.
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Print ISSN: 0003-4819 | Online ISSN: 1539-3704
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