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 (60 million) from South Africa's total HIV budget (.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 1 180 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 20 per PWH and 140 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.