AIDS: Invest Now Or Pay More Later

GUEST ARTICLE AIDS: Invest Now or Pay More Later

SETH BERKLEY, PETER PIOT, AND DORIS SCHOPPER

human immunodeficiency virus (HIV). Since greater because it mainly affects productive S DEVELOPING coun- the beginning of the epidemic, over 14 million young adults, and the resultant illnesses lead persons have probably been infected and over to demands for costly care. tries seek the most cost- 2 million have died. There are cost-effective interventions to effective ways to control The HIV epidemic is still growing—unlike slow the epidemic, yet current annual world- fil many other relatively stable diseases such as wide expenditure on AIDS prevention is only the spread of AIDS, the malaria—and holds the potential to become about $1.5 billion a year, with perhaps less World Development Report 1993 one of the most costly and debilitating epi- than $200 million of this spent in developing argues that no country is demics for developing countries. While HIV is countries. Among them, Thailand spends the still less common than diseases such as most ($45 million in 1992, 75 percent of which immune. Delaying action will malaria, its economic impact per case is far was from government funds), whereas total sharply raise the cost of spending throughout Sub-Saharan Africa was only double this amount, a mere 10 percent of intervening and increase the Developing countries bear the which came from government funds. heaviest burden threat the epidemic poses to A recent WHO study suggests that compre- Estimated distribution of HIV prevalence hensive services to prevent AIDS and sexually development. Without a cure, in adults, late 1993 transmitted disease (STD) in all developing prevention holds the key, along (millions) countries would cost $1.5 billion to $2.9 billion a year. While this would be a substantial with research on vaccines and Sub-Saharan Africa 7.00+ increase in current spending, WHO estimates South and Southeast Asia 2.00 that the number of new adult HIV infections treatments Latin America and the Caribbean 1.00+ North America .80 averted could be as high as 9.5 million over the Western Europe .40 next decade. This article looks at the most Although the first cases of AIDS were not North Africa and Middle East .08 cost-effective ways to fight the spread of identified until 1981, the virus has now spread Eastern Europe and Central Asia .05 East Asia and Pacific .03 AIDS, drawing heavily upon the studies worldwide, with cases reported in 173 coun- Australasia .02 undertaken for the World Bank's World tries. The World Health Organization (WHO) Development Report 1993. estimates that, currently, over 12 million per- Global total 11-12 sons—90 percent of whom live in developing Source: World Health Organization. Why a special case? countries (see table)—are infected with the For developing countries, a key question

40 Finance & Development / June 1994

©International Monetary Fund. Not for Redistribution these days is how much of limited gov- Moreover, the effects of losing an adult ernment funds should be spent on Chart 1 persist into the next generation as chil- The shifting trend among regions dren are withdrawn from school to help fighting AIDS, especially given that (estimated global annual AIDS incidence) there are other diseases that currently at home. exact a higher toll. The WDR 1993 Preventing AIDS prevents argues that the spread of HIV and other key transmissible diseases. AIDS merits special and immediate Efforts to slow the spread of HIV attention for several reasons: will also reduce the magnitude of the The HIV epidemic is bad and STD and tuberculosis (TB) epidemics. getting worse. The HTV virus is STDs are extremely common (over 250 spread in three ways: through sexual million new infections worldwide contact, through contact with contami- per year), are harder to treat in nated blood or blood products, and HIV-infected individuals, and have from mother to child during the perina- severe, often irreversible consequences tal period with an additional risk dur- that disproportionately compromise ing breast-feeding. In developing women. Besides their enormous bur- countries, HIV is ostensibly an STD, den, STDs increase by three- to fivefold with over 85 percent of infections the transmission and acquisition of occurring through heterosexual inter- HIV. course. Source: World Health Organization. For individuals previously infected Available evidence suggests that all with the tuberculosis bacillus, infection HTV-infected individuals will ulti- with HIV is one of the most important mately suffer from AIDS and that all factors promoting the development of AIDS patients will die within a few years. care giver for those infants not infected will active tuberculosis. There are estimated to be Because, on average, it takes six to ten years contribute to a reversal of the long-term down- more than four million persons dually for an HIV-infected adult to develop AIDS, ward trend in child mortality. In these heavily infected. TB is already the first and second regardless of future changes in HIV transmis- affected countries, population growth rates ranked cause of disease burden in young and sion, there will be an increasing number of will decline substantially, although due to the middle-aged males. In females, it ranks second AIDS cases over the next few years. Already, high fertility rates, growth will still be posi- and third in the same age groups. Increasing the estimated 12 million infected individuals tive. But it is in Asia where the virus is numbers of active TB infections will lead to constitute about 2.4 percent of the world's spreading fastest (Chart 1). In Thailand, 2 per- further spread in both the HTV and non-HIV global burden of disease—the present value of cent of the adult population is already infected populations. future streams of disability-adjusted life years infected, and India is in the midst of an explo- The cost-effectiveness of the avail- (DALYs) lost as a result of death, disease, or sive epidemic. able interventions rapidly declines as injury. This measure attempts to gauge the AIDS is an especially costly disease. the epidemic spreads. Since there is no full loss of healthy life. At the macro level, AIDS poses a threat to eco- vaccine or cure for AIDS, primary prevention But even these figures obscure the true nomic growth in many countries already in is the only current method of fighting the magnitude of the epidemic. In young adults in distress. Indeed, World Bank simulations indi- epidemic. Without it, AIDS spreads rapidly developing countries, HIV/AIDS is already the cate an annual slowing of growth of income in the transmission, or "core," groups—those greatest cause of disease burden in males and per capita by an average 0.6 percentage point particularly vulnerable to acquiring and the fourth greatest cause in females. per country in the ten worst affected countries transmitting infection due to high-risk activi- Conservative projections indicate that the in Sub-Saharan Africa. ties—followed by a slower and then accelerat- number of persons infected with HIV will The powerful negative impact of AIDS on ing spread in the general population (Chart 2). increase to more than 26 million in the year households, productive enterprises, and coun- Thus, early and effective targeting of HIV 2000, with 1.8 million deaths that year alone, tries stems partly from the high costs of treat- interventions is critical because the cost-effec- contributing about 3.3 percent to the global ment, which divert resources from productive tiveness of these interventions diminishes as burden of disease. Given the short time it investments, and mostly from the fact that the infection moves out of the high transmis- takes infection rates to double in many devel- AIDS primarily affects people during their sion groups into the general population. oping countries and the recent spread to coun- economically productive adult years, when Studies in nine developing and seven high- tries with low infection levels, total figures in they are typically responsible for the support income countries suggest that preventing one 2000 could even be two or three times higher. and care of others. case of AIDS saves, on average, about twice Of course, there are large differences in One study in a rural African community the GNP per capita in discounted lifetime infection rates among regions and within has shown that 89 percent of the deaths in the costs of medical care. In some urban areas, the regions. For a long time, Africa, where it is population of those 25-34 years can be savings may be as much as five times GNP estimated that HIV accounts for 6.3 percent of attributed to HTV infection (an excess mortal- per capita. Moreover, indirect costs are an esti- the burden of disease, had to contend with the ity of 13/1,000). These adult deaths can tip mated five to ten times higher. In Thailand, for most rapid spread of the virus. In some vulnerable households into poverty. Even in example, calculations suggest that if we could African populations, 1 in 40 adults is already Tanzania, where the government pays a large slow transmission rates by just 20 percent, infected, whereas in certain capital cities, the share of health costs, a Bank study shows that discounted savings in medical costs by the prevalence of infection is as high as 1 in 3 sex- affected rural households in 1991 spent year 2000 would be $1,250 per currently ually active women. The deaths of their $60—roughly the equivalent of annual rural infected person, or a potential total of $560 infected offspring as well as the loss of the income per capita—on treatment and funerals. million. As fewer persons overall would be

Finance & Development / June 1994 41

©International Monetary Fund. Not for Redistribution infected in the future, the stream of savings infections. Similar programs have been devel- ment. For those with symptoms who seek would continue to grow. oped in many other countries, including at treatment, charges for clinical services may Prevention involves sensitive, politi- least 22 in Sub-Saharan Africa. reduce access to adequate care, thereby cally charged issues. Preventing HIV Reducing blood-borne transmission. increasing the spread of STDs. Because of the infection often necessitates working with Only about 5 percent of all HIV infections primary and secondary benefits of treating socially marginalized groups (including, in occur as a result of blood transfusions, but STDs, it would make good sense to subsidize many cultures, homosexuals) and people who transmission with infected blood almost the delivery of STD services, including case practice illegal activities (e.g., drug use or always leads to infection. Preventive measures management and counseling, condom promo- prostitution). This means that unusually include reducing the need for transfusions, tion, and partner notification. Combining STD strong government commitment is essential to selecting low-risk blood donors, eliminating and family planning services is another good implement effective prevention programs. In payments for donated blood (because paid strategy. addition, because of the stigma attached to donors tend to have a higher risk of HTV), and Providing voluntary testing and HTV infection and the long time lag counseling. Easy and inexpensive vol- between infection and the onset of AIDS untary access to HIV testing gives people symptoms, governments often do not Charts an opportunity to take responsibility for assign high priority to HIV prevention Early AIDS intervention is crucial their own sexual behavior and ensure their until the epidemic has spread deeply into Simulated AIDS epidemic in partner is not infected Studies suggest the population. a Sub-Saharan African country that counseling and testing help individuals and couples adopt safer sexual behav- What can be done? ior. The once prohibitive cost of testing A combination of strategies, backed by has declined sharply thanks to new tech- adequate resources, is required to stem nology—testing now costs around $2 a AIDS. couple (excluding counseling). Experience Providing information. Informing from Uganda, where a voluntary testing people about how to protect themselves center was set up in 1990, shows the against HTV infection is central to any demand is high. AIDS strategy. They need to know that HIV testing, however, is not always reli- the risk of infection can be minimized by able because there is a short period when reducing the number of new sexual part- HIV may not be detected in a newly ners, choosing partners of the lowest risk, infected person. Furthermore, a negative refraining from risky sexual practices test result is no guarantee of continuing such as anal sex, seeking treatment for risk-free behavior. This means that testing other STDs, and avoiding contact with is most useful for couples in or planning a infected blood. long-term monogamous relationship. Encouraging condom use. Condom Governments will need to ensure that test- use is effective in slowing the spread of ing remains voluntary and anonymous, is both fflV and STDs and needs to be of high quality, and is accompanied by the Source: Adapted from Potts, Anderson, and Boily, Lancet 338 encouraged in all risky sexual encounters. (September?, 1991). appropriate counseling. Programs to promote condom use in Caring for the infected. Individuals highly vulnerable groups are very cost- who are ill from HIV-related illnesses effective. One such program, geared to low- screening blood. Effective early treatment of demand care, and, unless this care is planned income prostitutes in Nairobi, reduced the health problems, combined with the education for, AIDS treatment has the potential to over- mean annual incidence of gonorrhea from 2.8 of health care providers, can reduce blood whelm clinical capacity and result in a deteri- cases per woman in 1986 to 0.7 cases in 1989. transfusions by up to 50 percent. Intravenous oration of care for other illnesses. In 1992, A model of HIV transmission indicates that drug users can lower their risks by using developing countries spent about $340 million use of condoms averted 6,000-10,000 new HIV clean needles. to care for AIDS patients. While this is only a infections per year, at an approximate cost per Integrating AIDS prevention and small fraction of the $4.7 billion spent by DALY of about $0.50 per year of life saved. STD services. Little of the ADDS prevention developed countries to care for their AIDS This compares favorably with the most cost- budgets has been allocated for preventing and patients, it is still nearly twice the amount effective of all health interventions. treating other STDs. Yet, because the effi- spent on AIDS prevention in the developing Social marketing—the marketing of a con- ciency of transmission of HIV is increased by world. If spending per patient remains con- sumer good to fulfill a public health or other STDs, and STD patients and their partners stant, the amount spent on the care of AIDS social need, with retail costs subsidized by the are an important high-risk group to target, the patients in developing countries will more public sector—is another strategy. In Zaire, wide availability of STD services is crucial for than quadruple to $1.5 billion in the year distribution outlets—from pharmacies to tra- fighting AIDS. Treatment of STDs is also 2000. Strategic planning for care programs, ditional healers and from nightclubs to street important in its own right: these diseases including the use of a small number of rela- vendors—were saturated with subsidized alone account for the second largest disease tively inexpensive drugs and outpatient or condoms. Condom sales rose from 20,000 in burden (behind maternal causes) in women community treatment where possible, can 1987 to 18.3 million in 1991: 90 percent of the aged 15-44 in developing counties. greatly reduce costs. Palliative home care condoms were bought by men and 60 percent Because many STDs are asymptomatic, using a basic visitation program is relatively were intended for casual sex. In 1991 alone, especially in women, infected individuals fre- inexpensive but imposes a heavy burden on the program averted an estimated 25,000 HIV quently are unaware and do not seek treat- family members.

42 Finance & Development I'June 1994

©International Monetary Fund. Not for Redistribution Seth Berkley Peter Piot Doris Schopper a US citizen, is Associate Belgian, is a physician and Swiss, is a physician in the Director of Health Sciences Director of the Division of Planning and Policy for the Rockefeller Research and Intervention Coordination Unit, Global Foundation. A physician Development, Global Programme on AIDS, the and epidemiologist, he was Programme on AIDS, the World Health a member of the World World Health Organization. Development Report 1993 Organization. team.

Need for urgent action early spread of HIV or little HIV but a high NGOs—many of which have initiated rapid Despite national and international attention prevalence of STDs (e.g., Yunnan Province in and innovative responses to the and the significant effort by WHO to help China and Surabaja, Indonesia) should under- epidemic—can play a vital role in prevention, design and implement plans for controlling take massive, targeted preventive activities for care, and community support, using their AIDS, most national AIDS programs are cur- high-risk groups, including prostitutes, sup- credibility and access to reach those at highest rently inadequate. They often remain limited plemented by general education and testing of risk. Governments should maximize this to ministries of health, are too standardized, the blood supply. advantage by providing a supportive environ- and—until recently—lack STD control as a • Areas with a current epidemic, but as yet ment for NGO activities. significant contribution to AIDS prevention. little incidence of disease (e.g., urban areas of Although effective interventions now exist, Because of its vast demographic, social, eco- India), need to develop AIDS prevention pro- research is urgently needed to further develop nomic, and political implications, AIDS is not grams for the entire population while continu- new prevention technologies such as female- simply a health problem; it is a national devel- ing to target high-risk groups. Voluntary HIV controlled barrier methods (e.g., vaginal opment issue. National leadership and the testing and counseling and preparation for the microbicides) and vaccines that are appropri- involvement of multiple sectors are thus cru- care of AIDS patients should also begin. ate and affordable for developing countries. cial. The most effective programs, such as • Areas with a major epidemic and a high Although current antivirals are only partially Thailand's, pursue strategies that involve disease burden (e.g., Uganda and Zambia) effective and too expensive for most persons many agencies, both inside and outside gov- have to combine a broadly based preventive in developing countries, new agents are being ernments, in an atmosphere of openness and strategy with attention to care for AIDS developed. It will be critical to formulate frankness. patients. strategies that make these affordable for those Each country will have to tailor its ADDS Preventive efforts must be targeted at popu- living in developing countries. control plans to a number of local lations with diverse needs. For the high-risk In addition, many critical questions remain factors—including the epidemiology of HTV, groups (e.g., mobile population groups such as unanswered. Why is the efficiency of hetero- the capacity of the health system and other long-distance truck drivers, migrant workers, sexual transmission higher in some settings related sectors, and the available financial young urban adults, prostitutes and their (e.g., Africa versus the United States)? What resources. Countries with a significant burden clients, and injecting drug users), key inter- percentage of transmission is caused by of HIV disease will also need to develop strate- ventions include providing education on safer breast-feeding, male noncircumcision, and gies for financing and providing care for sex, promoting condom use, and treating various STDs? What factors enhance infec- infected individuals, as well as for those indi- STDs. For young people—half of all HIV tion from mother to child, and can the mecha- rectly affected (e.g., orphans whose parents infection has occurred in people under age nism be blocked? And are there really those have died of AIDS). 25—there is an urgent need for comprehen- who are "resistant" to, or have developed Three main criteria can be used by sive education on reproductive health issues, immunity to, infection? resource-constrained developing countries to both in and out of school. In addition, preven- The danger right now is that although most prioritize HIV/AIDS interventions: current tive efforts should be truly sensitive to the of the world's population—excepting parts of HIV prevalence, risk of future spread based on needs of women and young girls, helping them Africa and Southeast Asia—still live in com- the prevalence of STDs, and existing AIDS to protect themselves. Women are biologically munities that have low levels of HIV, these burden. According to these criteria, four dis- more susceptible to acquiring infection areas are nonetheless at great risk. If these tinct situations emerge. through heterosexual intercourse than men, communities wait until they recognize signifi- • Areas at low current risk, with little and they are also epidemiologically more vul- cant illness from HIV before acting, the epi- spread of HIV and few STDs (e.g., rural China nerable as they tend to marry or have sex with demic will most likely have penetrated deeply and North Africa), should emphasize compre- older men, who are more likely to be infected. into the population, at which point HIV will be hensive reproductive health education for Social factors such as double standards for much more costly and difficult for the world youth and some AIDS prevention among high- virginity and for fidelity after marriage, along community to halt. Without a major increase risk groups and should establish sensitive with the sexual subordination of women, rep- in resources, as well as political will and lead- HIV and STD surveillance to provide early resent additional risks. In Uganda, more than ership, the HIV epidemic is likely to become a warning of impending spread. 60 percent of HIV-infected persons are women, development disaster of unprecedented pro- • Areas at high risk of an epidemic from many of whom are faithful to one partner. portions. •

Finance & Development / June 1994 43