Health Affairs, 28, no. 6 (2009): 1575-1577 doi: 10.1377/hlthaff.28.6.1575 © 2009 by Project HOPE	New Online   Senate Health Reform Bill   Rewarding Providers   Public Option Policy Brief   Health Reform & Abortion   Delivery System Reform

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Fighting HIV/AIDS

PROLOGUE

The Difficult But Necessary Choices In Fighting HIV/AIDS

Stefano Bertozzi, Tyler Martz, and Peter Piot cover the history of the pandemic and the alternating optimism and despair about ever getting it under control. They note how hopes once centered on rapid development of a vaccine, although it has since proved far more difficult than anticipated to thwart the virus’s grip on the human immune system. Even a partially effective vaccine—like the two-part combination used in the Thai Phase III trial that lowered the rate of infection by 31.2 percent—would make a huge difference. Therefore, as Anthony Fauci and Greg Folkers argue, it’s essential that there be substantial increases in the funds spent on the HIV/AIDS basic scientific agenda beyond the more than several billion dollars a year expended now. Also essential is research to develop new drugs to deal with HIV’s growing resistance to the drugs now in use.

The advent of those antiretroviral drugs was one of the bright spots in the grim HIV history—as were eventual price reductions that made it possible to expand access for patients beyond those in the richest nations. As a result, HIV/AIDS became, in 2006, the first and so far the only disease for which the United Nations declared the goal to be universal access to treatment. However, the continued high level of HIV incidence, and consequent growth in prevalence, make that goal look far less realistic for much of the world’s HIV-positive and at-risk population. HIV-related deaths in 2007 are estimated at 2.0 million, versus 2.7 million new infections. So long as new cases outpace deaths, prevalence—already about 33 million people worldwide—will continue to grow. As modeling for the AIDS 2031 project by Robert Hecht and colleagues shows, even some plausible changes in strategy—particularly in the realm of prevention—do not appear adequate to keep the number of new cases from rising.

The situation is particularly dire for those countries, mostly in Africa, that combine high prevalence, low incomes, and heavy dependence on external assistance to finance their AIDS programs. Markus Haacker’s projections show that the total cost of fighting the epidemic in thirty-four of the poorest and most affected countries will grow from US$7 billion in 2007 to US$13.5 billion by 2015. Over that period, the portion of funding that must come from external donors will rise from US$4.1 billion to US$6.6 billion—more than a 50 percent increase in less than a decade. Overall, the AIDS 2031 estimators project, resources needed to fight HIV and AIDS could reach as high as US$19 billion–US$35 billion annually by 2031, or US$397 billion–US$722 billion over the next twenty-two years. Who will provide that large, long-term pool of funds is a first-order question.

Difficult decisions must be made among categories—making investments in research, prevention, treatment, care of vulnerable orphans and children, and altering social drivers of the pandemic—and within those categories as well. It is not a simple matter of deciding between preventing new cases and treating those already infected. Neither does treatment automatically deserve priority on ethical grounds, as Dan Brock and Daniel Wikler demonstrate. If all lives are equally valuable, the task is to save lives at the lowest cost by spending on the most cost-effective interventions in both categories. None of these decisions can be made in isolation, as actions selected in one area will critically affect all others.

Prevention. Prevention of HIV/AIDS has been remarkably successful in Thailand and Uganda, as well as in some richer countries. Yet it hasn’t succeeded globally nearly as much as needed; even in Washington, D.C., it has until recently shown poor results, as Alan Greenberg and colleagues discuss. Different preventive interventions are aimed at different population groups and show very different degrees of success in slowing the epidemic. It will be necessary to distinguish among preventive activities and give priority to those aimed at high-risk groups and to particular interventions with the highest payoff. Spending money on free needles for injecting drug users, for example, is probably a better use of funds than spending on free condoms for the broader population. It is also critical, as Judith Auerbach argues, to take a longer view and put more money and effort into changing the social drivers of the epidemic, such as enhancing the social and economic status of women.

Treatment. The issues in the treatment realm aren’t easy, either. Many HIV-positive people are already not getting treatment—and in all likelihood, treatment will reach an even smaller share of those needing it in the near future. This is a dreadful prospect on many counts. Although untreated people will die sooner, they may also spread infection faster. What’s more, treatment is relatively uniform, so there is no good basis for deciding who should receive it and who should not. There is also a widely felt moral imperative not to abandon those already in treatment, even if that means denying care to others with an equal claim on our sympathy and resources. Yet continued failure to treat all HIV-positive people—in fact, worsening failure, if incidence stays ahead of the rate at which people are brought into treatment—means rationing.

There is no consensus on how to ration—by either stopping treatment after an interval or distinguishing among which newly infected people should have priority access to antiretroviral drugs. Governments, donors, and the major AIDS-related programs—the Global Fund to Fight AIDS, TB, and Malaria and the President’s Emergency Program for AIDS Relief (PEPFAR)—therefore face difficult choices about treatment just as they do about prevention. Perhaps the lone bright spot is that treatment itself can probably be made more efficient and less costly. Still lower prices for antiviral drugs, stable funding for treatment, better-organized drug supply chains, closer monitoring of results, and other improvements could allow more people to be treated or release resources to use for prevention. Anil Soni and Rajat Gupta lay out these possibilities.

Collectively, these papers do not tell the world exactly what to do; in fact, they caution against simple, uniform prescriptions. But they do point in the direction of the following conclusions. First, if substantially more resources are not made available to combat HIV, then shifting some expenditures from treatment to greater prevention efforts looks justified, painful as such a shift would be. But that does not mean that every dollar taken away from treatment to spend on prevention would represent an improvement—or that new money for prevention would be effective, no matter how it were spent. The evidence so far is that some portion of both treatment and preventive activities has been partly wasteful. Switching from one kind of waste to another would not help, so resources must be devoted to those activities that would prevent the greatest number of deaths for the dollars spent.

The papers also point to the conclusion that if substantially more resources are devoted to HIV, treatment can and should be expanded. Everything that can be done to make treatment cheaper and more efficient should be done. And, in the short to medium term, resources that come from international donors need to be concentrated on the poorest countries with the highest HIV prevalence, leaving middle-income countries to pick up most or all of the burden themselves. As Jeffrey Harris explains, the world also needs to recognize and prepare for the nonscientific challenges—logistical, financial, and legal—of actually delivering an effective HIV vaccine, if the scientific problems can be overcome.

None of this will be easy. But the urgency to do something—to try anything that might slow the epidemic or reduce the damage from it—has to be resisted, as this impulse alone will make a poor guide to policy. But neither should the world recoil from the choices, or consider the task ahead so difficult that it gives up the fight.

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