Elliot Marseille, lead author, said: "Since the (United Nations) Global AIDS Fund has received commitments to date totaling only one-fifth of what will be needed every single year to provide for both prevention and treatment, we cannot duck the question, 'Where can this money do the most good?'"
Marseille, a public health researcher and health economist at the Institute for Health Policy Studies at the University of California at San Francisco, and his co-authors presented data and calculations showing in the 48 African nations south of the Sahara desert, it is 28 times cheaper to prevent acquired immune deficiency syndrome, which develops from the human immunodeficiency virus or HIV than to treat a patient who has developed full-blown AIDS.
The authors urge spending money to ensure a safe blood supply, using drug therapy to prevent mother-to-child transmission of HIV, voluntary counseling and testing, and sex-worker intervention programs. In general, public money should not be spent on drug therapy for people with AIDS, the authors said.
The paper cites a study in Kenya that showed every $8 to $12 spent on workers for sexual disease transmission control and on condoms prevented one case of AIDS. Even cut-rate drug treatment for AIDS costs $350 yearly per patient in Africa.
The HIV/AIDS epidemic now affects 25 million people in sub-Saharan Africa, approximately 68 percent of the world's cases. Most HIV transmission in Africa is caused by sexual contact between men and women.
Several official estimates conclude about $10 billion annually is needed in the developing countries to fight AIDS. Only about 20 percent of this amount is being raised and spent, the authors said.
Co-author James G. Kahn said more than $10 billion is spent each year in the United States alone to combat HIV and AIDS. Kahn is a physician and public health specialist at UCSF.
The Lancet paper uses a complex calculation, called the disability adjusted life year, or DALY, to compare treatment and prevention costs and arrive at the 28-1 cost ratio of treatment versus prevention. The calculation takes into account added length of life as well as improved health of those who are not ill.
The calculation values a year of life of a healthy person more than a year of life of people who are severely ill. The researchers also assumed there were no costs involved in the administration of antiretroviral therapy drug programs for HIV/AIDS, only the cost of the cut-rate medications.
The calculations assume highly active antiretroviral therapy, the preferred treatment for AIDS, could be provided for $350 a year per patient. Helene Gayle, director of the HIV/AIDS-Tuberculosis program for the Bill and Melinda Gates Foundation, which has committed $450 million to combat HIV/AIDS in Africa, commented on The Lancet paper.
"I think they're largely on the mark, but I think that framing it as prevention versus HAART is probably not necessarily useful; that is, talking about it in terms of absolutes, as if all prevention funding needs to be in place before looking at access to therapy," Gayle told United Press International.
"I think it's more of a continuum and having a prevention foundation is critical to build access to care. But I think realistically, at a country level, there may be multiple things going on at one time. Some of what we do goes beyond a cost-effectiveness analysis. Some of what we do, we do because it's the right thing," Gayle said.
Among those who object to the notion that antiretroviral therapy should not be publicly funded for Africans is Vincent Idemyor, a clinical pharmacologist and an authority on HAART treatment of AIDS.
"Basically (the authors) are implying that the 25 million plus people who are infected in sub-Saharan Africa should die. I am surprised that The Lancet would publish an article like this. There is enough money in the world to handle the AIDS cases in sub-Saharan Africa, if there is a will," Idemyor said.
"Both approaches are important. Prevention is important and treatment is important. But you cannot say that prevention should be funded before HAART. That's ridiculous," he added.
Idemyor is director of pharmaceutical services at Advocate Bethany Hospital in Chicago and is on faculty with the department of medicine at the University of Illinois College of Medicine, also in Chicago.
In some ways the authors of The Lancet paper agree with Idemyor. "The primary message from what we're doing is that the international fund is tremendously underfinanced at this point and that is a huge moral failing of the industrialized world," Kahn told UPI.
Thomas May, the director of graduate studies in bioethics at the Medical College of Wisconsin in Milwaukee told UPI, "The (Lancet) paper is correct in its primary points. ... It's always difficult when we talk about how to spend health care resources to decide between tangible cases versus statistical cases. The cases that are prevented through preventive programs are statistical cases or abstract cases versus the existing AIDS cases that are very tangible."
(Reported by Joe Grossman in Santa Cruz, Calif.)
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