Evaluating the Fiscal Impact of Antiretroviral Therapy for the Management of HIV in the United States 1987-2023.

Purpose: Investments in antiretroviral therapy (ART) have shown to improve outcomes for those living with human immunodeficiency virus (HIV) and reduce exposure to and transmission of the virus. In the current work, we assess the impact of ART on government public accounts since its introduction in 1987. Methods: National HIV epidemiological data from 1987 to 2023 were compared to a hypothetical no ART treatment scenario. This scenario was based on time series analysis, and on a transmission equation based on the effectiveness of ART. In the absence of historical epidemiological data, trend extrapolations were considered. The model assumes that individuals on ART are virally suppressed and, conservatively, excludes the impact of pre-exposure prophylaxis. The resulting differences in the number of HIV infections, acquired immunodeficiency syndrome (AIDS) cases and HIV-related deaths per year, were then considered to evaluate the impact on the labor market and on healthcare costs, based on the literature. The impact on employment was then used to estimate tax revenue and social benefits transfers. Results are presented separately with and without longevity effects. Results: The investment in ART from 1987 to 2023 was estimated to prevent millions of new infections and AIDS cases and to avoid HIV-related deaths. This investment was estimated to provide a return of US$2.11 trillion from 1987 to 2023; each US$1 spent on ART was estimated to create a revenue of US$4.3 to the public sector in the USA. Results remained positive when longevity effects were included. One-way sensitivity analysis showed results were robust. Conclusion: The analysis illustrates the broader economic benefits to the government attributed to public and private investments to develop and make ART available. The fiscal analysis of investing in ART shows a fourfold gain for the US government. This broader analysis is crucial to help shape health policy and funding decisions.