*Note: This is Part 1 of a three part series on the effectiveness of HIV/AIDS interventions*
The economists conducted a first-ever cost-benefit analysis of the top AIDS-fighting approaches by comparing the costs of prevention and treatment options per lives saved. The group told representatives of global organizations at Georgetown University that more cost-effective ways to prevent the spread of the disease are an HIV vaccine, infant male circumcision, preventing mother-to-child transmission of the disease and making blood transfusions safe.
This week, US Today ran a story on ReThink HIV’s research into the cost-effectiveness of HIV/AIDS interventions. The article coincides with the present budget debate, which could lead to funding cuts for major US government HIV/AIDS programs like PEPFAR.
The effectiveness versus efficiency debate is something we discussed at length in a course I took this spring entitled “Comparative HIV/AIDS Interventions in Africa” at Texas A&M University. Too often, results from randomized controlled trials (RCTs) are taken as effective ways to curb the spread of the disease everywhere. Instead, these results should be seen as efficient in a controlled environment and effective (at most) within the communities that the RCT was conducted.
The research that ReThink HIV is conducting appears to tackle this problem head-on. However, the organization lacks the community-based approach that is necessary in implementing successful HIV/AIDS interventions. Preliminary results reported in the USA Today article make the same sort of sweeping, generalized assumptions as previous research.
The question is: can we make universal proclamations about what works in HIV/AIDS prevention? I think the answer is no. HIV/AIDS primarily spreads through blood transfusion, mother-to-infant transmission, contact with contaminated needles, and sexual contact. Sexual contact is the most difficult to tackle because it involves taking into account various cultural and behavioral norms.
The preliminary results of the ReThink study argue that behavior change interventions are not among the most cost effective methods of preventing the spread of HIV/AIDS. Instead, they argue that more funding should be allocated to the pursuit of the mythical HIV vaccine. I agree that finding a vaccine for the disease could be the most cost-effective means of fighting the disease. But this is assuming that such a vaccine is possible to manufacture and will be affordable and available to everyone. The majority of HIV/AIDS cases in the world today are in sub-Saharan Africa, where access to basic health care is still scarce and where vaccinations are still rare and expensive. Given the nature of the pharmaceutical industry and existing infrastructure, it’s a big assumption that, even if we were to find a vaccine, this vaccine would be available to everyone.
Other cost-effective prevention strategies that the study recommends are already receiving a lot of attention. The spread of HIV through blood transfusion has all but disappeared in developed countries as blood banks cleaned up their supplies and implemented mandatory HIV testing prior to blood donation. However, developing countries still struggle to ensure safe blood transfusions. Cleaning up blood banks is particularly important because the chances of transmission are about 90% when a transfusion is made using HIV-infected blood. According to the University of California at San Francisco, 2-4% of all HIV infection cases worldwide are still attributed to blood transfusion. This is a low number, but does indicate that work still needs to be done. There is significant funding for cleaning up blood banks. For example, in 2006, 17% ($84 million) of the U.S. Government’s PEPFAR funds were for blood safety and safe medical injections. Maternal health has also received significant funding under the Millennium Development Goals, including prevention of mother to child transmission (PMTCT). For example, from 2002-2007, the PEPFAR funding supported PMTCT programs for over 10 million pregnancies.
In a way, the ReThink results are a “no, duh!” moment. Of course these strategies are cost effective; they avoid any controversial topics and are easy to implement across the board. The final strategy they recommend – infant male circumcision – is a bit more controversial. In the next segment, I’ll tackle the ReThink study’s assertions about male circumcision as prevention of HIV/AIDS.