Research spotlight: Projecting the impact of funding cuts to the President’s Emergency Plan for AIDS Relief (PEPFAR)

Summary:

This analysis projects the impact of funding cuts to PEPFAR (the President’s Emergency Plan for AIDS Relief), a U.S. program whose investments in curbing the global HIV/AIDS epidemic have saved over 25 million lives.

Given uncertainties about future PEPFAR funding, we modeled the impact of abrupt PEPFAR cutbacks in South Africa.

We found that eliminating PEPFAR would lead to 601,000 HIV-related deaths, 565,000 new HIV infections, and would increase population-level healthcare expenditure by $1.7 billion due to increased HIV prevalence and a less healthy population over the next decade in South Africa alone.

On January 20, 2025, PEPFAR aid for all countries was abruptly paused for 90 days, bringing heightened importance to this study’s findings.

Background:

This work was conducted prior to the Executive Order on Jan. 20, which immediately froze all funds to PEPFAR programs all 55 supported countries, and its results have direct implications for the impact from the interruptions that have occurred since then.

Our 25-year collaboration with South African investigators and work with HIV simulation models uniquely positioned us to project the clinical and economic consequences of cutting PEPFAR funding.

Approach:

We sought to project the impact of abrupt PEPFAR cutbacks in South Africa, a country with a high HIV prevalence and substantial contributions from PEPFAR.  

We used the CEPAC model, a microsimulation model that projects lifetime health and economic outcomes on an individual and population level.

Over 10 years, a 50% decrease in funding would lead to 315,000 HIV-related deaths, 286,000 new HIV infections, and decrease the average life expectancy of people living with HIV in South Africa by 2.02 years.

A 100% decrease in funding would lead to 601,000 HIV-related deaths, 565,000 new HIV infections, and decrease average life expectancy by 3.71 years over the same time frame.

Under decreased spending scenarios, individual healthcare expenditure among people with HIV would decrease by negligible amounts of up to $1,140 over a lifetime, because of people with HIV dying sooner. Population-level healthcare expenditure, however, would increase by up to $1.7 billion over 10 years due a population that is sicker due to lack of access to routine HIV care and a significant increase in HIV prevalence.

Clinical Implications:

Under the current 90-day freeze in PEPFAR aid disbursements, a disruption that was implemented with no warning, people living with HIV in the 55 PEPFAR-supported countries will face barriers in accessing regular treatment as well as testing and prevention.

Abrupt stoppages mean that clinics are not staffed for people to pick up their medication, even if those medications are available, and healthcare workers cannot work. People living with HIV become sick and may die, and transmission of HIV across the community will skyrocket, with substantial risk for transmission of treatment-resistant virus. Many of these impacts are irreversible.

We hope that the findings from this study will underscore the clinical and economic consequences of abruptly defunding PEPFAR and that they may inform decisions made by the U.S. government regarding PEPFAR funding.

Abruptly stopping of PEPFAR funding could have a striking, deleterious lasting effect on the progress South Africa, and all other countries, have made in controlling the HIV epidemic.

Any cost savings will likely be short-lived and come at the expense of over 550,000 new HIV infections and over 600,000 additional HIV-related deaths in South Africa by 2034. South Africa has a health system where the majority of HIV funding is provided by the national government. In countries whose PEPFAR transition to local funding is less strong, the impact could be far worse.

This analysis demonstrates the importance of PEPFAR as both a life-saving program and a bridge to self-sustaining national HIV programs, with benefits across the world.

Authors: In addition to Neilan, Mass General Brigham authors include Aditya R. Gandhi, Emily P. Hyle, Andrea L. Ciaranello, and Kenneth A. Freedberg. Additional authors include Linda-Gail Bekker, A. David Paltiel, and Yogan Pillay.

Conflicts of Interest: The authors declare no conflicts of interest. 

Source of funding: This work was supported by the National Institute of Allergy and Infectious Diseases [R37 AI058736 to KAF], Eunice Kennedy Shriver National Institute of Child Health and Human Development [R01 HD111355 to AMN], MGH Department of Medicine Transformative Scholars Award [to AMN], MGH Executive Committee on Research Claflin Distinguished Scholars Award [to AMN], James and Audrey Foster MGH Research Scholar Award [to ALC], and the MGH Jerome and Celia Reich Endowed Scholar in HIV/AIDS Award [to EPH]. The contents are solely the responsibility of the authors and do not necessarily represent the official views of the funders. 

Paper cited: Neilan AM et al “Potential clinical and economic impacts of cutbacks in the President’s Emergency Plan for AIDS Relief program in South Africa: a modeling analysis” Annals of Internal Medicine DOI: 10.7326/ANNALS-24-01104