Doing More with Less

Last week, the Global Fund, the world’s largest multilateral source of financing for the fight against AIDS, made a grim announcement: its donors had cut their funding by $1.6 billion, a big enough bite out of the organization’s budget that the fund would be bankrolling no new AIDS treatment projects until 2014.

The announcement casts a pall on the international community’s observance of World AIDS day this week, an occasion on which, the Global Fund’s problems notwithstanding, we have a great deal to celebrate.  Never before have we had the abundance of tools to fight the global AIDS epidemic that we have today. Male circumcision has proven a powerful means of reducing infection — a free circumcision service offered in South Africa’s Orange Farm township, for example, reduced HIV prevalence there by 55 percent. An article published in the New England Journal of Medicine suggested that putting HIV-infected patients on antiretroviral drugs immediately after they were diagnosed dramatically reduced the risk of infecting their partners. Looking forward, although hopes for the impact of a microbicide gel to reduce infection amongst women appear dashed — at least for the moment — early stage HIV vaccine trials have shown 90 percent success.

Meanwhile, 33 developing countries have seen annual rates of new HIV infections drop by a quarter or more from their peak. From 2006 to 2010, the number of people in developing countries on antiretroviral drugs tripled to over 6 million. Costs for those drugs have come down markedly; antiretrovirals that went for $1,100 a year in 2004 can now be had for $335. The annual death toll from the disease plateaued in the middle of the last decade and has since begun to drop. Between 2002 and 2006, AIDS mortality in Kenya fell by 29 percent.  These breakthroughs give new hope in the struggle against a disease that has devastated some of the world’s poorest countries, killing 30 million people and infecting 30 million more worldwide.

But the breakthroughs don’t amount to a global reprieve — and last week’s reminder of the perennial uncertainty surrounding the resources available to fight the epidemic, on top of news that donor funding for HIV/AIDS leveled in 2009 and then declined 10 percent in 2010, should be a wake-up call to focus on cost-effective responses.

Doing that requires getting our balance of treatment and prevention right. Because for all the promise of recent advances, we are not expanding treatment rapidly enough to cover the newly infected. For every new recipient of retroviral drugs, two people get infected. And while costs of treatment are dropping, they are not doing so fast enough. Today, as much as four-fifths of the cost of AIDS treatment in developing countries goes not to the drug but to the staff, health system administration costs, and testing necessary to deliver it — costs that are harder to reduce with a technological breakthroughs.

Meanwhile, health economist Mead Over, my colleague at the Center for Global Development, suggests that even if the money were found to start everyone who tested positive for HIV on an early course of retroviral drugs, under even the rosiest of scenarios the number of people living with AIDS in Africa would continue to rise until 2046 — as would the costs of treating them, which would hit $60 billion a year. That’s nearly equal to total aid flows to Africa in 2010. In fact, according to OECD statistics, AIDS and other reproductive health services already suck up more aid money than all other health spending combined in Sub-Saharan Africa — and they aren’t delivering the biggest health bang for their buck.

For a start, AIDS prevention is not only better than treatment, it is cheaper, too: Mead Over estimates that adult male circumcision costs about $42 per year of life saved from lower HIV infection rates, compared to $780 per life year saved by antiretroviral treatments. Or compare AIDS programs to other underfunded health priorities in the region. The World Bank estimates that additional vaccination coverage against diseases like measles, tuberculosis, or diphtheria in Africa costs from $1 to $5 per life year saved. For bednets and mosquito nets used to fight malaria, the figure is between $2 and $24.

That’s not to say AIDS funding should be reduced: there should be more resources for both AIDS and other health emergencies in Africa. And regardless, it is not clear that money dedicated to AIDS would be redirected to other health issues; to some extent treatment money is anchored by the implied commitment on the part of the U.S. government and other donors to continue funding in order to cover the treatment costs of those currently receiving drugs. If not for that anchor, there is little reason to assume funding wouldn’t be withdrawn as part of general budget cuts.

Nevertheless, it does suggest the urgent need to focus resources on the combination of interventions that will allow for what Over calls an "AIDS transition," in which the number of new infections falls below the number of AIDS deaths, so the number of people on treatment –and the cost of that treatment — starts to drop. He reports that Rwanda may be an early success story in that transition: 94 percent of those who are known to need antiretrovirals are being treated, while the rate of new HIV infections has dropped below AIDS deaths in 2007 and 2008. In part that’s thanks to active counseling, near-universal testing of partners of people infected with HIV, and ubiquitous testing of pregnant women.

If we can’t rapidly achieve a similar transition worldwide, we may have to start contending with painful tradeoffs. Researchers at the University of Cape Town have discussed the idea of choosing between "comprehensive treatment to fewer patients or universal access to a more limited package of benefits" — limits might include only providing access to the cheapest antiretrovirals, limiting laboratory testing, and deploying nurse-driven rather than doctor driven treatment, for example.

Without a lot of additional money — and that doesn’t look likely any time soon — each new person put on treatment takes resources that could be used to stop additional people getting infected in the first place, through programs like cash payments to girls who remain in school, for instance, or funding free adult male circumcision. It is an unquestionably grim choice to have to make, but prioritizing prevention is the best way to do the most good for the most people.