UCSF health economists urge global AIDS fund to finance prevention first

By Jeff Sheehy

Funding proven HIV prevention interventions in sub-Saharan Africa is 28 times more cost-effective than funding highly active antiretroviral therapy (HAART), even when HAART is priced extremely conservatively, according to UCSF researchers.

“Focusing first on relatively inexpensive prevention efforts such as ensuring a safe blood supply, using antiretrovirals to prevent mother to child transmission of HIV, voluntary counseling and testing, and sex worker intervention programs will save the maximum number of lives with the limited funds available,” said Elliot Marseille, DrPH, MPP, principal research associate at UCSF’s Institute for Health Policy Studies and lead author of the article which appears in the May 25, 2002 issue of The Lancet. 

Marseille is also affiliated with UCSF’s AIDS Research Institute.
“Pointing out that spending money on HIV prevention is at least 28 times as efficient in saving lives as spending the same money on HAART generates controversy. But since the 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?’” said Marseille.

The article assigns a conservative cost for the delivery of HAART—$350 per disability-adjusted life year (DALY). DALY is the standardized measure of health benefit that reflects years of life saved by an intervention adjusted for the quality and socio-economic value of each life-year saved. 

The $350 cost is based on the lowest available discount price for the standard three-drug combination therapy for one person for one year that has been offered by the Indian generic manufacturer, Cipla, to Medicins Sans Frontieres.  No other costs are attributed to the delivery of HAART for the purposes of the cost-effectiveness comparison with prevention programs. The $350 estimate also assumes perfect adherence to the drugs and no increased risk behavior as a result of access to HAART.

The annual cost for HAART is compared to the cost for implementing six prevention interventions that have proven successful in averting HIV transmission in developing countries-ensuring a safe blood supply, using antiretrovirals to prevent mother to child transmission of HIV, voluntary counseling and testing, sexually transmitted disease (STD) control for commercial sex workers, female condoms for commercial sex workers and STD control for the general population. (Co-infection with a STD makes an HIV-uninfected person more susceptible to HIV infection and also greatly facilitates the transmission of HIV by an HIV-infected person.) The average cost-effectiveness of delivering these interventions is $12.50 per DALY.
With HAART costing $350 per DALY, these prevention interventions have a 28 to 1 advantage.

“The tragic reality is that a dime a day from every American-much less than a dime if the other rich countries also participate-would pay for both prevention and substantial levels of treatment. 

Until policymakers decide to commit the estimated $10 billion a year that is needed, hard choices focused on saving the most lives have to be made,” said Marseille.

Co-authors of the article are Paul B. Hofmann, DrPH, FACHE, Provenance Health Partners, a healthcare management consulting firm, and James G. Kahn, MD, MPH, UCSF associate professor at UCSF’s Institute for Health Policy Studies and AIDS Research Institute.

This research was funded from a grant to the Societal Institute for the Mathematical Sciences from the National Institute on Drug Abuse.