Potential Clinical and Economic Impacts of Cutbacks in the President's Emergency Plan for AIDS Relief Program in...

Future U.S. congressional funding for the President's Emergency Plan for AIDS Relief (PEPFAR) program is uncertain.

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.

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]).

Published HIV care continuum; PEPFAR funding estimates.

South African adults (HIV prevalence, 16.2%; incidence, 0.32 per 100 PY).

Lifetime.

Health care sector.

PEPFAR funded 100% (PEPFAR_100%), 50% (PEPFAR_50%), or 0% (PEPFAR_0%).

HIV infections, life expectancy, and lifetime costs (2023 U.S. dollars).

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.

Countries with similar HIV prevalence and greater reliance on PEPFAR funding could experience disproportionately higher incremental infections and survival losses.

Budget fungibility and exact programmatic implications of reducing PEPFAR funding are unknown.

Abrupt PEPFAR cutbacks would have immediate and long-term detrimental effects on epidemiologic and clinical HIV outcomes in South Africa.

National Institutes of Health.