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Background: The United States is a giant in the global fight against HIV/AIDS. The bipartisan foundation of PEPFAR in 2003 transformed the world´s approach to anti-retroviral therapy in developing countries, and the US is the largest contributor to the Global Fund. However, the isolationism of the Trump Administration may soon place these activities under threat.
Methods: To test the potential impact of changes in American HIV/AIDS funding policies, we employed a mathematical model of the HIV epidemic and response across 18 countries in sub-Saharan Africa. We used financing data from PEPFAR, the Global Fund, and the IMF to estimate the US share of the total HIV/AIDS response historically and in future. We then removed this US share from the total funding available, or changed the way it could be allocated to future prevention efforts, to explore a series of alternative policy strategies that the administration might adopt.
Results: The model finds that US participation in the AIDS response is likely to have averted 2.5 million AIDS deaths and 21 million HIV infections in sub-Saharan Africa between the start of the epidemic and the end of 2016. Looking forward, sustained US funding could avert 300,000 AIDS deaths and 8.4 million HIV infections on the subcontinent between now and 2030. If the US instead withdraws from the funding landscape, for example by defunding PEPFAR in 2017 and breaking its pledge to the Global Fund, the cost could reach 298,000 AIDS deaths and 7.9 million HIV infections by 2030. How funds are disbursed also matters. If the new administration continues to fund PEPFAR but turns a moralistic blind eye to sex workers and gay men, an avoidable 239,000 AIDS deaths and 5.4 million HIV infections could occur.
Conclusions: Our work suggests that the choice before the US government is stark: it can shirk the mantle of global leadership in the AIDS response and thereby reverse the past decade of progress against the epidemic, or it can continue to fund PEPFAR and the Global Fund and potentially save 8.4 million people across sub-Saharan Africa from infection with HIV.