Background: Resource-limited nations must consider their response to potential contractions in international support for HIV programs. Objective: To evaluate the clinical, epidemiologic, and budgetary consequences of alternative HIV program scale-back strategies in 2 recipient nations, the Republic of South Africa (RSA) and Cô te d'Ivoire (CI). Design: Model-based comparison between current standard (CD4 count at presentation of 0.260 × 109 cells/L, universal antiretroviral therapy [ART] eligibility, and 5-year retention rate of 84%) and scale-back alternatives, including reduced HIV detection, no ART or delayed initiation (when CD4 count is <0.350 × 109 cells/L), reduced investment in retention, and no viral load monitoring or second-line ART. Data Sources: Published RSA- And CI-specific estimates of the HIV care continuum, ART efficacy, and HIV-related costs. Target Population: HIV-infected persons, including future incident cases. Time Horizon: 5 and 10 years. Perspective: Modified societal perspective, excluding time and productivity costs. Outcome Measures: HIV transmissions and deaths, years of life, and budgetary outlays (2015 U.S. dollars). Results of Base-Case Analysis: At 10 years, scale-back strategies increase projected HIV transmissions by 0.5% to 19.4% and deaths by 0.6% to 39.1%. Strategies can produce budgetary savings of up to 30% but no more. Compared with the current standard, nearly every scale-back strategy produces proportionally more HIV deaths (and transmissions, in RSA) than savings. When the least harmful and most efficient alternatives for achieving budget cuts of 10% to 20% are applied, every year of life lost will save roughly $900 in HIV-related outlays in RSA and $600 to $900 in CI. Results of Sensitivity Analysis: Scale-back programs, when combined, may result in clinical and budgetary synergies and offsets. Limitation: The magnitude and details of budget cuts are not yet known, nor is the degree to which other international partners might step in to restore budget shortfalls. Conclusion: Scaling back international aid to HIV programs will have severe adverse clinical consequences; for similar economic savings, certain programmatic scale-back choices result in less harm than others.
