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Wednesday, December 1, 2010

HIV Negativity

Irony Alert: Today is World AIDS Day.  The publishing of this post was not timed to coincide with the event, but pretty cool, huh?

Living in Botswana, it’s hard to ignore it.  The estimates vary (as do the sampling techniques), but the most recent UNAIDS survey places Botswana’s HIV prevalence at 24.8%.  In Gaborone, the nation’s capital and largest city, the HIV rate is estimated at 40%.  Things have actually gotten better since 2002 when the government started distributing free antiretrovirals to its HIV-positive citizens.  While not curative, when taken properly these drugs can keep the virus at bay for decades.  They also have the added benefit of reducing transmission when HIV-positive individuals have sex with those who are HIV-negative.  While Botswana’s life expectancy was 32 years in 2003, today it has rebounded to 61.

There is no doubt that antiretrovirals (as well as other programs and technologies focusing on HIV treatment and prevention) can save lives.  But, without a strong health care  infrastructure we are unable to effectively deliver costly HIV interventions, severely undermining their impact.  If, as others have pointed out, there is funding to provide antiretrovirals to pregnant women with HIV, but no prenatal care, no surgical facilities for emergency caesarian sections, no trained surgeons, and no antibiotics for neonatal infections, then we may erase all the good of our initial intervention.  Like so many other medical treatments, antiretrovirals require a system of clinics, trained doctors and nurses, and supply chain management to prevent treatment interruptions, which can be disastrous in HIV treatment.  Without a primary care infrastructure, people will have a hell of a time consistently getting their HIV drugs.  Even if they do get their drugs, without a functioning health care apparatus they will be vulnerable to every other disease that plagues the developing world.  We treat their HIV only to watch them die of pneumonia, or diarrhea, or malaria, or a hearth attack, or liver disease...

It takes more than pills to keep you healthy.

Further, as I discussed in my last post, with limited funds dedicated to global health, being effective isn’t enough; interventions must be more cost-effective than the other plausible alternatives.  That way we are doing the most good for the most people.  Antiretrovirals can transform lives, but in starting a patient you are making a lifelong commitment to treatment.  These drugs can make people live a lot longer, but in doing so, necessitate more years of expensive treatment.  This is an excellent problem to have (if only we could do so much for people with lung cancer or ALS), but one with many long-term implications.  If we cannot afford to offer drugs over the long term, then patients will eventually fall ill again: levels of the HIV virus begin to rise within days of stopping the medication, undoing all the good gained from years of treatment.  Worse yet, interruptions of treatment breed resistance, making the virus harder (and more expensive) to contain in the future.  And, while it’s wonderful that there exist drugs that can keep someone with HIV alive for decades, we have to consider the cost of those drugs over that time and what we might have been able to do with all of that money over that same period.  It’s not that treating HIV is a bad deal, per se (at about $1,000 per life year gained it would be a no-brainer in America), it’s just that this money could be better spent elsewhere.

And it’s a lot of money.  In 2009, President Obama announced the Global Health Initiative, dedicating $63 billion to the developing world over six years.  Of that amount, over 70% is dedicated to HIV.  That means for every dollar spent on prenatal care, childhood immunizations, diarrheal disease, and malaria combined, two dollars are spent on HIV.  This pattern holds for countless other foundations, NGOs, and governments.  For the record, in low income countries, HIV accounts for approximately 5.7% of deaths.  In the meantime, the drivers of mortality in the developing world are underfunded, with 2,400 children dying every day of diarrhea.  November witnessed a fatal outbreak of measles—a vaccine-preventable disease!—in the Republic of Congo.

One may be forgiven for not noticing this.  After all, the New York Times runs stories like this bemoaning cuts in HIV funding, while glossing over the fact that that same money is being used for more sustainable and cost-effective interventions.  The Washington Post ran a similar article.  And Desmond Tutu’s op/ed in the Times struck a comparable chord.  But this criticism betrays a lack of understanding of the global burden of disease.

HIV is a tremendous problem in Botswana and many other countries in sub-Saharan Africa.  However, in the seven largest countries in the world by population (comprising 3.5 billion people), HIV isn’t the scourge it is in Botswana.  Sure, this list includes the United States (a decidedly rich country), but the rest of list is not so rich: Bangladesh, Brazil, China, India, Indonesia, and Pakistan.  These countries are home to some of the poorest people in the world and yet not one of them has an HIV prevalence greater than 0.6%.  (At the risk of digressing, did you know that in China HIV used to be known as aizibing, the "loving capitalism disease"?)  Pneumonia, diarrhea, and cardiovascular disease are all greater killers in these countries, but receive less funding.  By overfunding HIV interventions, we are underfunding the billions of people in these countries.

This guy's got bigger problems than HIV to worry about.

So why does HIV receive so much attention and so much money?  To address this, I have to diverge from an evidence-based approach to mere conjecture.  It is my theory that HIV simply scares us in a way that other diseases don’t.  In the late 1980s and early 1990s, we had little understanding of this new plague that was killing young people in the prime of their lives.  Uniformly fatal at the time, HIV represented something new and frightening.  On the other hand, every reader of this blog has had diarrhea and probably has a difficult time imagining it being fatal.  Even when it is extremely fatal and contagious, we call it something else like "cholera", further reinforcing the idea that "diarrhea" is not all that serious.  In our minds HIV is a harbinger of death while diarrhea is merely an inconvenience.  Perhaps we use this fear as justification for throwing money at HIV.  Or perhaps it's because today our treatments for HIV are so effective we want to share them with the world.  While noble, such an attitude fails to recognize the scarcity of global health funding and the dire need for rational spending.

These beds were designed for patients with cholera.  Still doubt the lethality of diarrhea?

I have heard the counterargument that HIV money is not fungible, that donors who give to HIV-related causes might not give anywhere otherwise.  If this is true, then please forward this article to them.  However, I believe that people aware enough to comprehend the seriousness of HIV, can also grasp the urgency of maternal and child care, the need for water and sanitation, and the importance of other elements of primary care.  I also have been told that HIV is not overfunded, but rather is only less underfunded than other diseases.  This may be true, but in a world of scarce resources, it is incumbent that we rely on cost-effectiveness to determine our priorities, and our current practices are not in line with such evidence-based decision-making.  It may be true that the increase in global health spending over the past decade has been catalyzed by the HIV pandemic—perhaps HIV has raised international awareness of the plight of the world’s poor—, however, this does not justify continuing the present imbalance.

An optimist may hope that HIV funding be spent to build sustainable public health infrastructure.  If such funds were used to build clinics and train local health workers, then they could be applied to help everyone in need, including—but not limited to— those with HIV.  Whether this is happening is an open debate—Paul Farmer and Laurie Garrett have discussed this in Foreign Affairs—, but the results have been far from encouraging.

In the end, it is essential that we have facilities, services, and personnel capable of handling all manners of disease.  If HIV is overfunded, the solution is not to increase funding of pneumonia, diarrheal diseases, or any of the other leading causes of death in the developing world.  If we’re looking for the biggest bang for our limited number of bucks, primary care infrastructure is the best bet.  Scattershot approaches to public health are ineffective for comprehensively combating disease and always leave us vulnerable to the next epidemic.  However, a firm and sustainable public health foundation equips us to deal with health challenges as they arise, be they new infections or chronic conditions such as cardiovascular disease and diabetes that are sure to increase in coming years.

The global burden of disease is strikingly conserved and ever dynamic.  Some diseases have killed for years, while each decade witnesses a new epidemic.  In our struggle to provide the best care for the most people in unpredictable environments, we must maintain a rational approach to resource allocation.  As such, we must face facts: HIV receives too much of a too small amount.


  1. We've discussed the reliability of those life-expectancy numbers for Botswana before but the tables have turned - last time I was the one credulously buying the figures in the 30s.

    If we can believe the CIA World Factbook then Botswana experienced one of the greatest public-health miracles in human history, nearly doubling its life expectancy in just 3 years. It would be wonderful if this were true; I wonder if you could get that kind of effect by implementing a universal pre-natal Nevirapene+c-section program in a country with sufficiently high HIV prevalence.

  2. Thanks for saying exactly what I was thinking.

    Building up infrastructure through PEPFAR seems difficult to argue for when the money is focused on paying high-salaried US consultants to work in Africa without having to leave their cubicles.

  3. Thanks Adam for sharing such a great and well-articulated post. It reminded me of one of your previous posts, where you described diseases like diarrhea as not passing the "bleeding out of your eyes" test the way ebola does. Do you think HIV/AIDS passes the sexiness test?

    If you haven't seen it already, here is an advertisement that Ogilvy produced for the Topsy Foundation, an organization that provides ARVs in South Africa. It is a real change in pace from the way HIV/AIDS is usually portrayed in the media - here it is quite an optimistic approach. Ogilvy won an award for this ad campaign at the Cannes festival last month:


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