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.

The Case for Cost-Effectiveness

It appears I’ve engaged in a bit of a bait and switch.  At the end of my last post I promised to address the issue of HIV-related health expenditures dominating global health budgets and the adverse effects of such overfunding.  And that was my intention.  However, as I sat down to write this post, I realized that, in order to make my argument, I had to establish the importance of cost-effectiveness in global health decision-making.  And so, while my next post will tackle the issue of HIV overspending, today I make the case for cost-effectiveness.

Say you’re on a sinking ship.  There are 1,000 passengers and only spots for 500 people on the lifeboats.  You would, of course, be justified in your outrage regarding the lack of safety precautions.  In general, the ratio of passengers to lifeboat spots should be pretty damn close to 1.  However, as HMS Pangea takes on water, you might be better served to determine who should get those spots on the lifeboats.

There are an infinite number of arguments that can be made for who should be put on those lifeboats. We could identify the healthiest people with the longest life expectancy.  Maybe we should save them so our survivors live for the most years.  Maybe we should we put all the kids on first, after all, children are among those least able to care for themselves and deserve succor first.  Maybe we should throw in a few burly men and women to help guide these individuals and ensure that those in the lifeboats make it safely to land.  Maybe the best swimmers should be left out of the boats—they have the best chance of making it to land on their own.

The arguments go on and on.  Our task today is not to determine who gets on those lifeboats, but to agree that somehow we need to make sure all 500 spots on those boats are filled in a manner that is both fair and rational.

This kid knows a thing or two about cost-effectiveness.

  

Erroneus! you say.  The urgency of a sinking ship is not comparable to the inexorable fight against poverty and disease.  But much like a sinking ship, health care and health tragedies change lives in a matter of minutes and hours, not months and years.  Waiting for a dose of life-saving antibiotics may be a race against the clock.  The same holds true for those desperately awaiting the next calorie or the man who needs emergent dialysis because his kidneys quit working weeks ago.  And it holds for the laboring pregnant woman with AIDS who needs antiretrovirals to prevent her child from acquiring HIV.  That these tragedies take place far away does not make them any less urgent.

Fine, you say, there is urgency.  But where is the scarcity?  Is it fair to compare efforts to aid the world’s sick to a sinking ship where only half of the passengers can be saved?  No.  It is an unfair comparison.  More than half of the world’s sick will fail to be rescued.

Resources for global health and development don’t have to be limited.  For about the cost of the Iraq War we could halve the global incidence of HIV in under 25 years.  Or perhaps less fashionably (but more cost-effectively), build a network of clinics throughout Africa, roads to connect them to towns and villages, and train doctors and nurses to staff them.

However, the fact of the matter is, there is a limited pool of money in the world and we all make choices about how it should be spent.  If our private boats were sailing near the aforementioned sinking ship, we would surely offer up some space for the stranded passengers.  But would we have donated to a fund to equip the ship with extra lifeboats to begin with?  Would we have elected to pay higher taxes to support the World Health Organization or USAID?  Let’s put it this way, the last time a major presidential candidate ran on a platform promising to raise taxes, he lost 49 of 50 states.

We all want to help, but there are other things we want as well.  Over the next two decades, Americans will spend more than the sum required to halve the HIV incidence on their pets.  The cost of an average wedding in America is more than the median income in dozens of countries.  I'm writing this on a pretty spiffy MacBook.  Resources for global health and development don't have to be limited.  But they are.  And so, the task falls to us to figure out how best to spend that money.

Cost-effectiveness makes us uncomfortable.  It sounds an awful lot like rationing or like valuing lives against each other.  Yet in medicine, we accept this all the time, even if we don't realize that we're doing it.  In transplant medicine—with fewer organs than patients in need—we are willing to offer the transplant to the person less likely to abuse alcohol or die of something else in the immediate future.  On the battlefields of World War I, the French came up with the notion of triage (from the French word for to separate).  In the chaos of war, army medics could not attend to all the injured soldiers so they made three categories: those likely to die regardless of intervention, those likely to survive regardless of intervention, and those that could survive but only with medical care.  It was the last group that got attention first because, with time at a premium, the medics wanted the biggest bang for their buck.  This system is still used in emergency departments throughout the world. 

In the U.S. medical system, where cost-effectiveness is explicitly not used, overuse of technology and resources is rife.  As such, every unnecessary test and procedure increases costs for insurance companies.  To recoup this loss, insurance companies raise premiums.  As premiums rise, families decide they can no longer afford health insurance and the ranks of the uninsured grow.  The cause and effect may be separated by months and miles, but the connection is very real.

Remind you of your local emergency room?

In determining cost-effectiveness, we usually look at an outcome related to years lived.  It is fair to question this outcome, as people's contributions to the world are not necessarily tied to their longevity.  However, we would not necessarily agree to base access to care on one's contributions to society in the first place (or even how to measure those contributions).  Longevity is also a problematic measure as people in some parts of the world have much shorter life expectancies than those in other parts.  Is it less cost-effective to help someone in Somalia rather than in France if she will not live as long after a given intervention?  And does cost-effectiveness diminish as those who are treated and live longer require more costly care in the future?  These are important questions and not easily answered.  In global health, if the money is limited (and it always is), then we have to figure out who to give it to and cost-effectiveness offers us a method.  We may not always agree on all of the variables in the equation, but my hope is that we agree that a calculation—even an imperfect one—is necessary.

The argument for cost-effectiveness does rest on the assumption of fungibility, the property of money that it can be substituted for itself.  By way of example, my grandmother used to give her grandchildren money when she visited.  She’d always tell us to spend it on whatever we wanted, except for alcohol.  As my financier cousin explained, despite being an formidable intellectual, our grandmother didn’t really grasp fungibility.  We could use her $20 gift to pay part of our rent and then take $20 out of our rent money to spend on booze.  Problem solved.  In terms of global health spending, cost-effectiveness is only relevant if funding is fungible.  If a donor (or donor country) will only give money if it is spent on HIV interventions, then it is irrelevant if that money could be more efficiently spent on primary care.  In that case, the cost-effectiveness argument has to be made to the donor, not to the NGO that is spending the money.

While this discussion can feel awfully utilitarian at times, it’s important to remember the gravity of its implications.  Proper regard for cost-effectiveness can help more people live longer and healthier lives.  The converse of this is true, too: disregard for cost-effectiveness can lead to unnecessary death and suffering.  Bioethicist and Obama adviser Ezekiel Emanuel and his colleagues put it eloquently when they wrote, “Because resources devoted to international health aid are inherently limited, seemingly economic considerations about cost-effectiveness actually reflect fundamental ethical principles.  The more cost-effectively resources are used, the more lives can be saved.”

We shop around for the best value on cars, computers, even groceries.  For nearly everyone, money is a finite resource and it is imperative that we spend it wisely.  That this should apply to the health needs of the world’s poorest and most vulnerable is merely a logical—and ethical—extension.