Health GAP Position Paper
www.globaltreatmentaccess.org | www.healthgap.org

So-called experts and policy makers have declared that anti-retroviral treatment (ART)for people in poor countries is not cost-effective. People in these countries, they say, will best be served by condoms and treatment of tuberculosis. Not surprisingly, many are the same people who previously said that there is no infrastructure in poor countries or that Africans cannot tell time. Despite the growing demand for a comprehensive approach to the AIDS epidemic that includes ART from activists in both the South and North, governments in the most impacted countries, and international leaders like Kofi Annan, these "experts" aggressively assert that they know better.

WHAT IS COST-EFFECTIVENESS?

When researchers test an approach to fighting HIV—testing blood transfusions for HIV, for example—they can use the information to estimate how many cases of HIV are avoided. Using some questionable premises and mathematical modeling, they then estimate how many years of life will be saved if that many cases of AIDS are averted. They then calculate how much that particular approach costs, divide the cost by the number of "life-years" saved, and come up with a dollar figure per year of life saved. There are refinements, but that's basically it.

Most people instinctively reject the cost-effectiveness framework but don't know how to respond other than saying that the value of a life can't be quantified. We have to be able to say more than that. The hard reality is that policy is now being made at governmental and international levels on how to move forward in fighting the epidemic, and many of the policy makers think (or want to think) that relying on the numbers generated by a few researchers can substitute for strategic thinking about how to impact on the epidemic.

WHAT'S WRONG WITH THE COST EFFECTIVE ANALYSIS OF AIDS TREATMENT?

The cost-effectiveness model is totally wrong for making the strategic choices about how to spend funds to fight AIDS.

Cost-effectiveness analysis fundamentally assumes that each human life is separate and so is each human death. While that may be a suitable assumption for comparing something like different ways to treat high blood pressure, it totally breaks down in the face of a massive epidemic of an infectious disease like HIV.

In countries where HIV infects a significant (greater than 5%) of the young adult population, we have to look on the impact on the society as a whole. This includes many of the countries in sub-Saharan Africa. As people go from asymptomatic HIV infection to AIDS, they lose the ability to work. If the person is the family breadwinner, the other adult(s) in the family will likely have to stay home to care for them. Children will be forced to stay home from school either to work themselves or because of a lack of funds to pay fees. Teachers, health professionals, and community organizers infected with HIV die, and the country loses the human infrastructure it needs to respond to the epidemic. The national economy itself is impacted, and governments that have chronically suffered from a lack of resources now have even less. This pattern is being repeated right now in country after country. Each person with HIV is part of a family, a social network, a community and a country, and when so many people are infected and dying all these other levels of social organization are damaged. To say that only prevention is cost-effective in saving lives is to damn those currently infected to premature death. But they are not isolated individuals: they are the life-blood of their countries.

To stabilize the situation in these high-seroprevalence countries with established epidemics, we have to quickly achieve two goals: we have to offer effective treatment to those already infected and we have to reduce transmission to those not infected. To only do one, or to pit them against each other, has not and cannot work.

WHY WON'T MATERNAL TO CHILD TRANSMISSION PREVENTION PROGRAMS SAVE THE FUTURE?

The prevention-only cost-effectiveness position will also guarantee that future generations will continue to suffer from high levels of HIV infection. This is the opposite of what the advocates of that position claim, but their claims are superficial and misleading. Just as HIV has an impact across an entire society, so too does it impact across generations.

The most obvious evidence of this are the millions of AIDS orphans. It's estimated that there are at least 12 million children under 15 in high seroprevalence countries in Africa whose mother/mother & father have died of AIDS. This is a tragedy of enormous proportions, and even politicians in the G-8 countries have begun to bemoan it. But bemoaning doesn't solve a problem, and we need to critically look at the "cost-effective" solutions being put forward.

We should first be clear that we totally support MTCT programs as a crucial part of any comprehensive set of policies for addressing the AIDS epidemic. However, it has clearly been shown (most recently by the Medical Research Council of South Africa) that MTCT programs alone without treatment for the parents will result in an increase of approximately 10% in the total number of AIDS orphans over the next ten years. The number of HIV-infected babies will have declined, perhaps up to 50%, but those that live who would have otherwise been infected will join their uninfected brothers and sisters as orphans.

The conditions of intense poverty, stigma and homelessness that these children face are perhaps the most painful part of the suffering inflicted on societies by the AIDS epidemic. These are also the structural conditions that make them highly vulnerable to HIV infection themselves. The one-step-at-a-time, cost-effective approach that will never result in ART being available to save the parents' lives inadvertently but predictably condemns the babies they hope to save to despair and infection.

But it is not simply those children whose parents die from AIDS who will be at higher risk. Because of the deteriorating economic and social conditions discussed above brought about the AIDS pandemic, the next generation of children in many African countries are facing a future of deepening poverty, poorer education and social unrest.

Is ART a magic bullet for these problems? Absolutely not, but it can help keep people alive while they, and the world, work on a longer term solution.

DOES COST-EFFECTIVENESS ANALYSIS HAVE ANY ROLE IN AIDS POLICY-MAKING?

Perhaps, but it cannot drive policy making. Only agreement on the basic objectives of a national or global policy can set the relative funding for each component. As we've seen, some of the current positions based on cost-effectiveness intentionally confuse the complementary goals associated with prevention and treatment (they all save lives, don't they?), and then use cost-effectiveness to liquidate any role for ART.

There may be a role for cost-effectiveness studies to compare activities that claim to achieve the same end. Even then, the studies must be done well and the researchers who do them must have the integrity to be clear about their limitations. Some of the work cited by policy makers does not meet these standards. One example is a recent article by researchers at the University of California San Francisco that called for policy to be based on cost-effectiveness. In arguing for essentially a "prevention-only" approach, they discussed the cost-effectiveness of STD (sexually transmitted disease) treatment as primary prevention for HIV infection. There is substantial epidemiological evidence that STDs can make catching and transmitting HIV more efficient, but that's not the same as showing clinically that treating STDs will lower the number of new HIV infections.

A study done in Tanzania addressed that question by doing mass treatment of STDs in some communities and not in others, and they were able to show that new cases of HIV did go down. That was an important finding and a cost-effectiveness study was done to estimate how much it cost to avert a new case of HIV through treating STDs. The researchers at UCSF cited that study.

They chose not to mention a very similar study done at the same by another group of researchers in neighboring Uganda. If anything, the researchers were even more thorough in treating STDs. When they looked at the incidence of HIV in the treated and control communities, they found absolutely no difference. There would have been no point in doing a cost-effectiveness analysis of this study because the STD treatment was not effective at all in reducing HIV. The cost would have been infinitely high.

First, is there an explanation for these contradictory results? The researchers from the two different studies got together, looked at each other's data, and wrote a paper together saying that they think they know why: the prevalence of HIV in Tanzania was about 5%, while the prevalence in Uganda was 15%. Since many other factors besides STDs can contribute to transmission of HIV (such as viral load), those living in Uganda were at great risk of HIV even if they were treated for STDs. Most scientists accept this explanation.

It shows a startling lack of integrity for the UCSF researchers not to mention these facts. It's particularly dishonest because in many of their other cost-effective analyses use models that have populations with 15-30% seroprevalence, much more similar to the Uganda study that they ignored than to the Tanzania study that they used. It's not that the Tanzania study shouldn't be used, it's that people trying to figure out how to control the AIDS epidemic need to have all the information. So, maybe STD treatment would be an important part of the package of services countries with seroprevalences of 5% or below, but in areas like that in Uganda, ART to lower viral load might be emphasized more.

This is just one example. The reality is that few good quality studies of the effectiveness of either prevention or treatment have been done in Africa, and fewer yet have cost-effectiveness analysis done. For cost-effective analysis to be useful at all, there need to be several studies to compare, and the studies need to be well done and produce good data. Most importantly, the people writing up this information have to be scrupulously honest. They have to understand that this is not a sterile academic debate where it might be acceptable to withhold information helpful to those who oppose you. There has never been an epidemic of such devastating impact, and everyone involved must have the humility to know that we all need each other to help figure out how to stabilize the global situation and slow the epidemic.

SUMMARY

One thing that we should all have learned about the HIV/AIDS epidemic by this time is that generalizations don't help figure out what to do for a particular person, a particular community, a particular country. "Prevention is cost-effective, treatment is not" is exactly that kind of generalization that will stop us from doing the strategic thinking that we all desperately need to do.

It seems clear that there needs to be a major investment in care and treatment in countries which have a mature (HIV has been present for 10 years or more), high prevalence epidemic where AIDS is literally threatening the survival of the people and the economies. There also need to be money for prevention so that new infections can be decreased. In countries with a relatively new epidemic (some of the Eastern European countries or China, for example), few people will be symptomatic and require treatment, and much more money needs to go into primary prevention to keep the numbers from growing. Even there, though, some funds should be used to build up the capacity to treat and thereby be ready when some of the infected people become symptomatic. And there are certainly countries in between, including many in Latin America and the Caribbean , where there are mature lower prevalence epidemics and where funds might be more evenly distributed. Only the specific countries, with assistance from international agencies if needed, can decide for their own societies.

People who continue to pit prevention against treatment must be closing their eyes to the realities in Africa and their ears to the growing calls from Africans and others around the world. People demand treatment because it gives them hope for themselves, their families and their countries. For a people reeling under the impact of an epidemic, a belief that relief from suffering is possible is critical to mobilizing them to fight, and AIDS will not be controlled by top-down efforts.

The prevention-only, cost-effectiveness advocates claim to be using common sense in a world where the wealthy countries won't give adequate funding for an integrated approach to fighting HIV/AIDS. That kind of "common sense" is simply a justification for the status quo. It's not the same as good judgment or strategic thinking. What we need are visionaries who are willing to confront the magnitude of the catastrophe we are living through and demand that the world respond with the resources required.

Dr. Alan Berkman, Health GAP