John Stover

HIV funding has been declining in the past decade creating a large gap in required funding. In 2024, UNAIDS (Joint United Nations Programme on HIV/AIDS) convened a Global Task Team in 2024 to recommend new targets and approaches for 2030 for key HIV interventions. This paper describes the approach to estimate the impact and cost of achieving those targets. We calibrated an HIV simulation model, Goals, to the historical HIV epidemic in 134 countries and used the model to project the impact of achieving the UNAIDS targets by 2030. Resource needs were estimated for 118 low-, lower-middle and upper-middle income countries (LMIC). To estimate the cost of achieving the targets we compiled a database of the unit costs for each intervention from published studies, country reports and commodity costs. Achieving the UNAIDS 2030 targets would reduce the annual number of new HIV infections globally by 77% from 2023 to 2030, from 1.3 million to 300,000. The number of AIDS deaths would decline by 50% over the same period. Resources needed to achieve the targets in all LMIC would rise to US$21.9 billion by 2030. Of this amount, 17% is needed in low-income countries, 38% in lower-middle income countries and 45% in upper-middle income countries. Achieving the UNAIDS targets for 2030 would reduce the annual number of new HIV infections to just 9% of the peak value in 1995 and AIDS deaths to 13% of the peak value in 2004. The resources required to achieve these targets are substantial but $7 billion less than previous estimates of $29.3 billion.

Introduction: The World Health Organization (WHO) endorses male circumcision as an effective human immunodeficiency virus (HIV) prevention intervention in settings where the expected impact is greatest, including Sub-Saharan Africa. Data on cost implications of early infant male circumcision (EIMC) are limited. The ShangRing (SR) is a WHO pre-qualified device for circumcision. We sought to perform a comprehensive cost assessment alongside a randomized controlled trial (RCT) of the SR versus the standard of care Mogen clamp (MoC) for EIMC to enable future scale-up towards a cost-effective HIV prevention strategy. Methods: We collected resource utilization and economic data as part of an RCT of infants aged 0–60 days old undergoing EIMC in Kenya, Tanzania, and Uganda. Cost data for both the SR and MoC included baseline facility costs, direct costs, and indirect costs. The Decision Makers Program Planning Tool v1.0 was used to perform a direct cost comparison of these two devices. The Goals model was used to compare the costs of EIMC in 2023 using the present value of money to circumcise an adolescent male 15 years from now. Results: A total of 1,378 infant males underwent circumcision, 689 via SR and 689 via MoC. The overall cost of a single EIMC in Kenya, Tanzania, and Uganda were 61.30 United States Dollars ($), $47.14, and $64.59 respectively for the SR, and $56.38, $50.43, and $58.57 respectively for the MoC. In Kenya, EIMC would be less expensive based on nominal present costs in 2023 compared to waiting for adolescent circumcision at age 15 years in 2038. This finding is reversed in Tanzania and Uganda. Conclusions: The overall cost of EIMC via SR versus MoC is comparable in an RCT. With scale-up utilizing lower level personnel, the cost of SR may be further reduced. The SR is an attractive alternative for future EIMC initiatives in Sub-Saharan Africa to further reduce HIV burden.

Background: Antiretroviral therapy (ART) has greatly reduced HIV-related mortality and improved life expectancy in sub-Saharan Africa since the early 2000s. However, HIV-related mortality remains high. To guide intervention priorities, we used seven established HIV simulation models to identify where in the HIV care cascade deaths occur in Zimbabwe, Malawi, and South Africa. This multi-model approach provided a more comprehensive and robust assessment than could be achieved using any single modelling approach. Methods and findings: To assess alignment, each model generated key HIV metrics from 2000 to 2045, including total population, HIV prevalence, annual new infections, and proportions of people with HIV (PWH) who were diagnosed, on ART, and virally suppressed. HIV-related deaths were estimated annually and categorised by whether they occurred in individuals who were (1) undiagnosed, (2) diagnosed but had not yet started ART, (3) on ART, or (4) had interrupted ART. The models showed strong consistency with population estimates and HIV prevalence across the different settings. There was, however, variation in the absolute number of HIV-related deaths between models; in Zimbabwe in 2025, this ranged from 3,666 to 17,475; in Malawi from 4,580 to 17,835; and in South Africa from 39,470 to 114,968. In Zimbabwe, all models consistently indicated that PWH receiving ART made up the largest proportion of HIV-related deaths, though this proportion differed across models, ranging from 35% to 64%. This was followed by HIV-related deaths amongst those who had interrupted ART, ranging from 17% to 29%. Similar trends were seen in Malawi. In South Africa, a high proportion of HIV-related deaths occurred amongst people who had interrupted ART (23% to 74% in 2025) as well as those who were currently receiving ART (23% to 56%). Models are reliant on empirical data and limited data availability—in this instance, lack of national death registries—is a key constraint on modelling studies. Conclusion: Absolute numbers of HIV-related deaths vary substantially between models, highlighting wider issues around ascertainment of death in the region. However, our results do consistently show that most deaths are occurring amongst PWH on ART in Zimbabwe and Malawi, and amongst those who have interrupted treatment in South Africa, suggesting interventions around adherence counselling and retention in care need to be prioritised.

Objectives: Estimate fertility rate ratios (FRR) of HIV-positive relative to HIV-negative women in sub-Saharan Africa (SSA) by age group, CD4 stage, ART status, and country. Design: Analysis of nationally representative household surveys with HIV serological testing. Methods: We analysed current pregnancy and births in the past three years by HIV status from 72 nationally-representative household surveys in SSA between 2003 and 2017. Spectrum 2018 estimates for the distribution by CD4 stage and ART status were used to infer fertility of women on ART from changes in fertility of all HIV-positive women as ART coverage increased. We allowed regional differences in the age pattern of relative fertility and estimated country-specific random effects. Results: The ratio of fertility in untreated HIV-positive women with CD4 ≥500 to HIV-negative women was 1.6 to 1.8 for age 15-19, relatively similar to 10% times lower for age 20-29, and 15-50% lower above age 30. Among age 15-19, each 15-point increase in percent sexually active reduced relative excess fertility by 24%. Fertility decreased with lower untreated CD4 count stages, consistent with previous estimates. Women on ART >6 months had fertility closer to that of HIV-negative women for ages 15-29, but still 25-40% lower above age 30. There was substantial variation across countries. Conclusions: Fertility differences for HIV-positive women compared to HIV-negative women are smaller than previous estimates, but vary substantially across countries. Recent data suggest fertility of women on ART is greater than that of untreated HIV-positive women, but remains lower than HIV-negative women. This conclusion should be reviewed as new evidence becomes available.

Zimbabwe is highly dependent on United States Government (USG) funding for the HIV Response, where 42% of the HIV expenditures in 2020 were financed by the USG and in 2023, PEPFAR invested more than $200 million to support HIV programmes. In late January 2025, the USG issued a “Stop Work Order,” suspending funding for international aid and development during a 90-day review period and this was expected to have a significant negative impact on the Zimbabwean healthcare system therefore an epidemiological assessment was conducted to assess the impact of the stop work order. To assess the impact on incidence and mortality, an epidemiological assessment using the Avenir Health Goals model simulated five scenarios ranging from temporary pauses to the indefinite withdrawal of PEPFAR and 11% reduction in the Global Fund funding support. The stopping funding specified in the waiver plus 11% reduction in the Global Fund funding results in 74% (11,000) additional new HIV infections. The 90-day stop-work order will result in 35% (6,000) additional new HIV infections in 2025. The stopping of PEPFAR direct funding will result in additional 7,000 new HIV infections in 2025. Stopping all PEPFAR direct funding will add 35,000, 90-days pause will add 31,000, while stopping support to HIV prevention programs will add 22,000 additional new HIV infections through 2030. Stopping all PEPFAR direct funding will result in more than 13% increase in AIDS-related deaths with additional 107,000 deaths through 2030. The 90 days pause will reduce adult treatment coverage by 10% from 95% to 85% in 2025, while stopping direct PEPFAR funding will result in a reduction in adult ART coverage by 40% to 55% in 2025. These disruptions pose a significant threat to Zimbabwe’s ability to achieve epidemic control and reach the 2030 target of ending AIDS as a public health threat.

Background: Global investments to combat HIV, tuberculosis, and malaria (HTM) have delivered substantial health gains and may have reduced the burden placed by these diseases on the routine health system. We estimated the reduction in primary healthcare (PHC) utilization resulting from the scale-up of HTM services over 2000–2023 in 108 low- and middle-income countries. Methods and findings: For each disease, we applied established mathematical models to quantify PHC utilization (outpatient visits and inpatient bed-days provided outside of HTM programs) by individuals with symptomatic HIV, tuberculosis, or malaria unable to access HTM-specific services. For each country, we estimated averted PHC utilization by comparing a scenario describing the actual scale-up of HTM services to a counterfactual scenario holding HTM service coverage constant at year 2000 levels. We applied published unit costs to estimate the averted costs resulting from reduced PHC utilization. Over 2000–2023, scale-up of HTM services averted an estimated 6.9 (95% uncertainty interval (UI) [4.4, 10.5]) billion outpatient PHC visits and 3.9 (95% UI [2.5, 5.9]) billion inpatient bed-days, representing US$135 (95% UI [71, 250]) billion in averted costs. These reductions were greatest in sub-Saharan Africa and East Asia and Pacific regions. Across study countries, these reductions represented a median of 4.4% of hospital bed capacity and 1.6% of government health spending in 2023. These percentages were 22.9% and 5.1%, respectively, for low-income countries. Our analysis did not consider changes in PHC services beyond utilization. Also, several inputs were missing in some countries, with missing values estimated using regression imputation. Conclusions: Over recent decades, sustained investments in HTM services in high-burden settings have averted substantial PHC utilization and associated costs. These benefits should be considered when assessing investment impact.