HIV Prevention 28 Times More Cost-Effective Than Treatment in Sub-Saharan Africa, Should be Priority for Funding, Researchers Say
A "small but influential group" of researchers from the Institute for Health Policy Studies at the University of California-San Francisco are calling for "limited" HIV/AIDS funding in sub-Saharan Africa to go toward prevention programs instead of treatment programs, the San Francisco Chronicle reports (Heredia, San Francisco Chronicle, 5/24). In an analysis published today on the Lancet Web site, the researchers state that proven HIV/AIDS prevention interventions in sub-Saharan Africa are 28 times more cost-effective to fund than highly active antiretroviral treatment programs. Dr. Elliot Marseille and colleagues compared the cost-effectiveness of HAART with six proven prevention strategies -- ensuring the safety of the blood supply, the use of antiretroviral drugs to prevent vertical HIV transmission, voluntary HIV testing and counseling, STD control for commercial sex workers, female condoms for sex workers and STD control for the general population -- to determine the cost-effectiveness in terms of disability-adjusted life years (DALY) saved. The lowest price offered for a three-drug combination of two nucleoside analogues and a protease inhibitor or a non-nucleoside reverse transcriptase inhibitor for one patient for one year was estimated to be $350 per DALY (this price is currently being offered to developing nations and non-governmental organizations by Indian generic drug maker Cipla). This price did not include the cost of delivery, storage or monitoring of the medicines or testing and monitoring of patients. After reviewing a variety of prevention interventions and their costs, the researchers determined that the average estimated cost of prevention was $12.50 per DALY. Comparing the costs of HAART to prevention yields a ratio of 28:1, "suggest[ing] that for every one life-year gained with HAART, 28 life-years could have been gained with prevention," the researchers conclude.
"Invariably, the economically advantaged will obtain treatment, so how can a system be designed that does not discriminate based on financial status?" the researchers ask, answering, "In the short-term at least, it cannot." Therefore, health officials must consider where limited resources will be most effective when allocating funding, they state (Marseille et al., Lancet, 5/25). Marseille acknowledged that promoting prevention over treatment would "generat[e] controversy" among those who advocate that the Global Fund to Fight AIDS, Tuberculosis and Malaria should provide grants for both prevention and treatment. Noting that only $1.96 billion has been donated to the fund so far, he stated that "[u]ntil policymakers decide to commit the estimated $10 billion a year that is needed, hard choices focused on saving the most lives have to be made. ... Focusing first on relatively inexpensive prevention efforts ... will save the maximum number of lives with the limited funds available" (UCSF release, 5/24).
'We Need Both'
The Chronicle reports that the "highly controversial idea is already drawing flak from experts and activists" who are working to obtain cheaper antiretroviral drugs for HIV-positive people in sub-Saharan African countries. Rachel Cohen, the U.S. advocacy liaison for Doctors Without Borders, "lambasted" the report as "archaic and small-minded." She said, "Offering treatment gives people incentive to come forward to get tested. It's the first step to prevention. The two go hand in hand. They can't be unlinked." She added that people in treatment could become "peer leaders" in HIV/AIDS prevention efforts and noted that other studies have determined that providing treatment in developing countries reduces hospital costs and "enabled people to become productive members of society again." Dr. Richard Marlink, executive director of the Harvard AIDS Institute, said supporting prevention without treatment sends the "wrong message. We need both. We need to treat those who are suffering. That we accept that we have to make these decisions is what is the moral outrage." Mark Grayson, spokesperson for the Pharmaceutical Research and Manufacturers Association of America, said the study was not "breaking new ground," noting that prevention and education "should be the major focus of most of the funds." But there is "still a place for therapy," he said, noting that officials have to "balance all the needs with what can be provided with the funds available" (San Francisco Chronicle, 5/24).