One year ago in his State of the Union Address, President Obama reaffirmed the United States' goal of achieving an AIDS-Free Generation. The year that followed brought fresh evidence that this goal is within reach: new HIV infection rates are beginning to fall in countries where people have access to HIV programs.
A major part of this success is the result of expanded access to HIV treatment, which has been shown to both save millions of lives and prevent HIV transmission. Moreover, an analysis by UNAIDS found that the faster countries scaled up access to HIV treatment, the faster their rate of new HIV cases fell. A study in KwaZulu-Natal, South Africa, determined that the risk of HIV infection was 38 percent lower in communities where HIV treatment had been scaled up.
The U.S. President's Emergency Plan for AIDS Relief (PEPFAR), regarded as one of the most successful global health programs in history, is currently helping provide lifesaving HIV treatment to 6.7 million people. The program has the potential to make major additional contributions in this area—and indeed 40 members of Congress recently asked that the program be expanded to reach 12 million people by 2016.
But it is deeply concerning that instead of reaching this bold goal, the pace of HIV treatment scale-up could slow considerably in the coming years because of budget cuts to U.S. global AIDS programs. Without new resources for PEPFAR, as well as additional program efficiencies, the number of new people put on HIV treatment with U.S. support will plummet. The graph below shows our analysis of the pace of scale-up under PEPFAR, based on publicly available data and consultation with experts in the field.
As the graph above shows, the number of people added annually to treatment through PEPFAR has increased dramatically since early in the program's history, with a high of 1.6 million people newly receiving treatment last year. This quickening pace of delivery was possible because the average per person cost of HIV treatment through PEPFAR fell precipitously over the years. Treatment expansion also benefitted from hundreds of millions of dollars in unexpended "pipeline" funds that were available in 2012 and 2013. If we stay on this course, we could reach 12 million or more people on treatment through PEPFAR by 2016—about a third of the HIV-positive people in the world.
Unfortunately, the treatment trajectory is now poised to turn downward. At current funding levels, treatment initiation through PEPFAR could fall back to the levels of the first years of the program, as shown above. The major factor is that bilateral global HIV funding has been consistently cut in the last several budgets, and is now $700 million below its peak in fiscal year 2010, according to the Kaiser Family Foundation. When you combine these cuts with the clearing out of pipeline funds, there are simply insufficient resources to expand HIV treatment at anywhere near the current pace. Some efficiencies may still be possible, but they are small compared to the overall budget. (Our estimates are based on data from the U.S. Government Accountability Office, PEPFAR reports to Congress, and reasonable assumptions about recent and future changes in federal funding and the cost of treatment. We welcome the opportunity to review our analysis with those who are interested.)
Slowing the pace of treatment scale-up would be an unfortunate choice and should not be seen as inevitable. Our estimates suggest that if President Obama and Congress can work together to reverse the PEPFAR cuts over the next two years—increasing the PEPFPAR bilateral budget by $400 million in 2015 and again in 2016—we can stay on our current trajectory. This moves us toward achieving the United Nations target of 15 million people with HIV on treatment by the end of 2015, and it also means reaching an end to the AIDS epidemic sooner. Sustaining this course, however, requires that the State Department free some money for HIV treatment in the current fiscal year, and continue to push for modest reductions in the PEPFAR cost of treatment. Without new treatment funding in fiscal year 2014, the pace of scale-up will slow markedly this year.
Allowing the pace of treatment delivery to slow down doesn't make public health or economic sense. A recent study found that HIV treatment programs in developing countries result in long-term economic returns of up to 287 percent in the form of increased labor productivity, averted orphan care, and deferred medical care. A World Bank study in Kenya showed that when AIDS treatment was expanded, adult working hours increased and children's nutritional status and school attendance improved. A Harvard analysis estimated that early initiation of HIV treatment in South Africa could generate cost savings over five years.
It is now possible to begin to end the AIDS pandemic, but doing so will require focusing resources on interventions we know work, including prevention of vertical transmission to newborns, voluntary medical male circumcision, harm reduction, targeted behavioral interventions, and HIV treatment. Research on a cure and a vaccine remains essential. And PEPFAR's partners, including affected countries and the Global Fund to Fight AIDS, Tuberculosis and Malaria, must do more. But there is no ending AIDS without scaled-up HIV treatment and without PEPFAR continuing to play a leading role.
The United States has staked out a leadership position on global HIV, and it has brought us tremendous returns in the form of millions of lives saved, an improved reputation in the world, and the opportunity to begin to end one of the worst epidemics of our time. It doesn't make humanitarian, diplomatic or economic sense to backtrack on HIV treatment scale-up now. Congress and the Administration must find the resources to keep PEPFAR on track to accelerate the end of AIDS.
This article originally appeared as a blog post on HealthAffairs.org.