2017 could have been worse. Although propelled to power by blustery threats to cut or eliminate publicly funded programs, including those that keep people living with HIV alive and well, the new administration has largely been unable to convert rhetoric into reality. Most notably, despite years of introducing bills calling for the immediate repeal the Affordable Care Act (ACA) and the termination health insurance for millions, Republicans now in control of Congress have become unwilling to see it go. As more than one observer has noted, it took the GOP to make Obamacare popular. Likewise, at least for now, the life-saving and disparity-reducing Ryan White Care Act programs, including state AIDS Drug Assistance Programs (ADAPs), have been able to continue to provide for people who are HIV positive. However, the first skirmishes of the budget battles are only now being fought, and the White House's initial proposal charted a scorched-earth approach of deep cuts to health care and research -- a typical extreme starting position.
That the cost of these threatened cuts to domestic and global programs can be tallied not only in dollars but also in deaths is the message of two papers published this past year. In the first, Walensky and colleagues modeled the clinical (HIV transmissions, deaths, years of life) and economic effects of various scale-backs in current HIV programs in South Africa and Côte d'Ivoire that could result from cuts in U.S. funding. These two nations were intentionally chosen as they have different HIV prevalence rates and levels of foreign aid. Several scale-back scenarios that could follow funding cuts were examined, including cessation of screening and new antiretroviral starts, reduced HIV testing and linkage, reintroduction of the 350 cells/mm3 CD4 cell count threshold for antiretroviral initiation, weakened retention in care, elimination of plasma HIV RNA testing, and no provision of second-line antiretrovirals. In the models performed, each of these scale-back strategies led to more HIV transmissions and deaths, usually with only modest economic savings. For example, the authors state that a strategy of decreased case identification and, therefore, late presentation of those infected, would reduce the HIV program budget by 13% in both countries but would lead to a projected increase in mortality of 22% in South Africa and 15% in Côte d'Ivoire.
Related: This Week in HIV Research: "Massive Loss of Life"
In a second paper, the same team of investigators flipped their analysis to examine the costs and benefits accrued with the scale-up of funding to attain the National HIV/AIDS Strategy (NHAS) goals in the U.S. Established by the Obama administration in 2015, this strategic plan set a target of 72% viral suppression for all those infected with HIV in the U.S. -- in alignment with the United Nations' vision of achieving the diagnosis of 90% of people living with HIV, treatment of 90% of those diagnosed, and viral suppression in 90% of those on treatment (90-90-90). Again, examining the clinical and economic impacts, the investigators found tremendous value in the investments needed to achieve the NHAS goal vis-à-vis expanded HIV testing and high-impact adherence and clinic-retention interventions. An estimated 23% increase over current expenditures ($120 billion over 20 years) to achieve the NHAS viral suppression goal would be expected over the next two decades to avert:
- 280,000 HIV transmissions, overall
- 80,000 HIV transmissions in black men who have sex with men (MSM)
- 199,000 deaths, overall
- 45,000 deaths in black MSM
Given the disparities and inequalities in the risk of HIV acquisition and adverse clinical outcomes for black people in the U.S. in general, and particularly black MSM, it is no surprise that there was more bang for each buck spent when interventions were targeted to support black MSM. The incremental cost-effectiveness ratio for NHAS compared with current spending was $68,900/quality-adjusted life-years (QALY) for the general population and only $38,300/QALY for black MSM -- ratios well below the $100,000/QALY that is generally accepted as the threshold for cost-effectiveness.
The Bottom Line
Many lives are affected by numbers on the line items of federal budget spreadsheets. These papers help to transform these numbers into the faces of those affected. Threatened cuts to the funding of HIV programs abroad (see figure) will save money in the short term but exact massive and tragic human costs. Ultimately, as the epidemic worsens where funding recedes, scale-back strategies are likely to be more expensive for U.S. taxpayers as societies and governments crumble and require urgent intervention.
The proposed budget also threatens the progress that has been made domestically. Realization of the NHAS goals will save almost 200,000 lives over the next two decades -- an extraordinary number. Again, the cost of averting a transmission is modest for the savings -- in lives and, ultimately, money. However, instead of investing in people, the current administration and Congress are working to dismantle the ACA, one of the more significant interventions benefiting Americans living with HIV. The expansion of Medicaid provided for by the ACA led to a drop in the proportion of non-elderly adults who are uninsured from 20.4% in 2013 to 12.8% in 2015. Unfortunately, many states, particularly in the U.S. South, opted not to expand Medicaid, and in these states, the uninsured rates among people living with HIV have remained stable at around 25% compared with almost being halved in states that chose to expand Medicaid.
Fortunately, not all is as bleak as a dystopian young adult trilogy. More than a sigh of relief, a cheer is in order given the congressional response to the administration's designs to slash National Institutes of Health (NIH) funding by over 20%. Instead, bipartisan support for the NIH and all it does to make the world a healthier place led to an increase of close to $2 billion to the NIH budget -- a significant rebuke to small-mindedness and a hopeful signal that reason can prevail where confusion and obfuscation reign. Whether Congress can muster similar resolve to fund compassionate initiatives at home and abroad may depend on our strong and vocal support for such programs.
David Alain Wohl, M.D., is a professor of medicine in the Division of Infectious Diseases at the University of North Carolina (UNC). He is site leader of the UNC AIDS Clinical Trials Unit at Chapel Hill, director of the North Carolina AIDS Education and Training Center (AETC), and co-directs HIV services for the North Carolina state prison system. In 2014, he became co-director of the UNC-Duke Clinical RM Ebola Response Consortium.