Search BMJ STI archive, and you will find frequent references to ‘scaling up’, and few – if any – to ‘scaling back’ or ‘scaling down’ (other than Parker/STI).  Who knows if all this may not be about to change, if the US government goes ahead with threats to cut current foreign aid budget ear-marked for HIV by $6.7 billion? How would this affect local HIV programmes?

Walensky & Paltiel  (W&P) model alternative strategies and combinations of strategies for the Republic of South Africa (RSA) and Cote d’Ivoire (CI) to determine which would offer the maximum budgetary return for each year of life lost. Strategies include ‘no new ART’, ‘reduced HIV testing and linking to care’, ‘ART eligibility at a lower CD4 count’, etc.; but all presuppose that commitments to those currently in ART care will be maintained. If scale-back is unavoidable, then it matters how those cuts are implemented; certain combinations of strategies, the authors claim, achieve synergies between strategies such that their combination produces budgetary savings that are greater, per year of life lost, than the total of the two strategies considered separately – for example, ‘late presentation’ and ‘reduced retention’ in RSA. However, ‘no new ART’ turns out to be the strategy that delivers the greatest budgetary savings in an ‘efficient’ manner.

It is hard to gauge the tone of these recommendations – which sound more like a ‘wake-up call’ to the US government than a sober proposal for scale-backs in sub-Saharan countries. Certainly this is not an argument for the long-term cost-effectiveness of any policy for scale-backs, since any short-term savings, they claim, will soon be overtaken by the downstream economic costs of increased HIV transmissions. And even the maximum of savings achievable by these strategies turns out not to exceed 30% of present expenditure. The most efficient alternatives for achieving cuts of 10%-20% will achieve c.$900 and c.$600-900 per every year of life lost in RSA and CI respectively.

In practice, however, it is hard to imagine the necessary cut-backs being achieved in so transparent and rational a manner. At all events, the effect of US cuts to HIV programmes will be presumably be more keenly felt – and will harder to make up for from other (e.g. local) resources – where the proportion of the national HIV budget funded by the US is higher. So, in CI, for example, where 90% of HIV spending comes from international sources, a 10% cut in PEPFAR (President’s Emergency Plan for AIDS Relief) funding would result in a 9% reduction in HIV spending, whereas, in RSA, where most of the funding is self-financed, it would represent a reduction of only 2%. It remains the case, however, that, in absolute terms, that 2% of spending in the RSA is worth $40 million, or double the $20 million saved by the 9% of savings in the CI.