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.

Are We Running Before We're Walking?

Researchers recently announced that they have discovered a medication that is highly efficacious in the treatment of the Ebola virus.  This is good news if you are one of the hundreds of people who are likely to get this virus in the next decade.  However, if you’re one of the 4,500 children in the developing world who will die of diarrheal disease in the next 24 hours, you may not view this as much of a triumph.

Ebola is sexy.  It passes the “bleeding out of your eyes test” so crucial for media coverage (that is, any disease that causes ocular hemorrhage tends to attract a good deal of mainstream coverage).  However, in terms of global health scourges, it doesn’t crack the top 10.

They probably won't get Ebola.

I don’t mean to be glib.  Anyone who has read the Hot Zone understands the graveness of an Ebola infection.  And Ebola’s penchant for devastation makes it a possible candidate for use in bioterrorism.  However, the drivers of death rarely make for compelling narratives, nor do they receive the funding they deserve.  The list of leading causes of death throughout the world includes many diseases that shouldn’t be fatal or shouldn’t occur in the first place.  Pneumonia (#3 worldwide, #1 in low income countries) is usually treated without hospital admission in America.  Ditto for diarrhea (#5 worldwide, #3 in low income countries).  Measles (#16)?  We average 56 cases a year in the U.S.

These diseases have at least one thing in common: there are vaccines that reduce (but do not eliminate) their incidence.  These vaccines are cheap, effective, and widely available in the developed world.  But vaccination requires more than vaccines;  an effective inoculation campaign relies on primary care infrastructure- both physical and human.  Want to give vaccines?  You probably need a clinic where patients can go.  That clinic needs doctors and nurses to administer the shots.  And electricity to keep the vaccines cold and unspoiled.  A medical records system would be helpful to keep track of who is due for their vaccines.  And, should someone get sick in spite of all of this, the clinic can serve as an early point of intervention where antibiotics or oral rehydration solution could be dispensed.

Ensuring that the health needs of the industrializing world are met requires a concerted effort to build capacity, not a scattershot approach targeted at the rarest and most shocking diseases.  Vaccines, health care workers, clinic construction, antenatal care, water and sanitation.  This is an argument I will return to time and again (and one made quite convincingly by Laurie Garrett) and you may even begin to agree with me.  But will you agree when I argue in my next post that overfunded HIV interventions are jeopardizing the very infrastructure I'm calling for?