What does HIV/AIDS cost? The answer to this question depends a lot on whom you ask.

Ask the UN and you’ll get the staggering sum of $10 billion. A year . The annual per capita cost of treating infected Africans, where much of the UN money goes, is around $1,100. One of the major problems facing HIV/AIDS advocates is their inability to lower this number. An estimated $600 is spent on anti-retroviral drugs, while the remaining $500 is spent on other AIDS associated conditions. Even $10 billion wouldn’t cover treatment for the more than 20 million Africans with HIV/AIDS. A considerable portion of the proposed UN budget is directed not towards treatment but towards prevention. A major problem is that no one can seem to agree on the actual cost. Although the UN has held firm to their estimate, other groups have presented vastly different figures. The World Health Organization has presented four different scenarios which vary wildly in both the projected outcome and cost. To merely maintain the current status quo, WHO estimates more than $400 billion will need to be spent over the next 20 years. To significantly reduce annual new HIV infections, WHO’s figure is more than $700 billion. Unfortunately such different figures can sometimes complicate funding by making it hard for donors to decide how much to give.

Ask someone who is living with HIV/AIDS and you’ll get a number that’s a lot smaller. The average AIDS patient in America takes a combination of drugs that add up to around $14,000 a year . Much of this cost in the US is defrayed by private insurance, government insurance or sometimes through AIDS drug assistance programs (ADAPs) . These programs are meant to provide access to drugs for low income individuals. Currently 89% of people enrolled in ADAPs make less than 300% of the federal poverty level. However recently the economic conditions have forced many states to scale back their support of these programs. States have either closed enrollment entirely, or narrowed eligibility-forcing people to drop out. Currently the nationwide waiting list is at an all time high of 3,586 people .



Ask the companies that manufacture these lifesaving drugs and you’ll be back to huge figures. One of the newest drugs to enter the market, Fuzeon , is produced by the giant Swiss company, Roche. Roche maintains that Fuzeon’s price (nearly $20,000 a year, or three times the next most expensive drug) is due to the $600 million cost of development. The average drug begins to turn a profit in 16 years, but analysts estimate that Fuzeon’s pricing, and anticipated demand, could mean profits for Roche in as little as three years.

Ask an economist and you’ll get a couple different figures. By 1995 more than $75 billion had been spent on AIDS. Since then, spending has increased most years, with an average of $10 billion more being spent every year. But money spent directly on AIDS does not even begin to cover the true cost. In addition, economists have tried to measure the costs related to lost productivity, wages, and premature death, due to the disease. Figures vary, but some think that indirect costs account for nearly 80 percent of the total cost of AIDS. Worst case scenario guesses estimate that AIDS robs the world of 1.4% of gross domestic product, or the equivalent of wiping out the economy of Australia .



A government study in Uganda found that some companies are hiring and training two employees for a single job in the hope that one will stay healthy. The UN estimates that since 1981 AIDS has reduced Africa’s overall labor force by 25%. Sick days and absenteeism due to AIDS related illness have further reduced productivity in the countries hit hardest by AIDS.

Ultimately the cost of HIV/AIDS is extraordinarily difficult to measure. The disease affects so many people worldwide that it would be impossible to assess the impact that it has had on everyone. However it is obvious that unless something drastic changes, the costs will continue to grow until they become unbearable.

A Picture of Life with HIV in Africa

Africa. The seed of the world. One of the most beautiful and most scintillating places on earth. From the deserts of the Sahara and the rainforests of the Congo to the bright and bustling metropolis of Cape Town, life is rich everywhere. Yet amidst all this beauty and splendor, a deadly scourge threatens the people of this continent. AIDS.

Sub-Saharan Africa is more heavily affected by HIV/AIDS than is any other region in the world. Somewhere around 22.4 million people in the region are currently living with HIV. This makes up a whopping two-thirds of the global number of HIV-infected individuals. Whereas in other areas of the world the disease affects only certain groups, here, HIV/AIDS affects everyone. This affliction picks apart whole extended families one by one. Schools are gradually emptied over time as students are orphaned. Healthcare and economic development have all taken a hard hit because of the impact of HIV/AIDS on the African peoples. Organizations simply don’t have the funds to support or expand prevention, treatment and care efforts and for this reason, it is likely that the death count will continue to rise. Life expectancy has been drastically reduced across the continent, falling to as low as 31 years in some of the worst afflicted areas. HIV/AIDS is present everywhere we look. It is an unavoidable aspect of everyday life.

The following dialogue includes excerpts from various interviews. I spoke with a group of college students who lived for six months in South Africa and Zambia, another student who lived 2 years in Nigeria, and a field biologist currently doing research in Cameroon. Their testimonies will enhance the picture of daily life in African countries afflicted with HIV/AIDS.

Take the country of Cameroon, for example. As of 2008, the population in Cameroon neared 19 million. Of that, about 600,000 are living with HIV/AIDS. More than half of that is made up of women 15 years and older. While prevalence here is much lower than other countries, HIV/AIDS remains a chief concern. When asked about general knowledge about the disease, most agreed that the “information is very available to middle and upper class citizens, but not necessarily to the lower class citizens and those that are at highest risk.” There is a large focus on prevention here, and the country is littered with billboards promoting abstinence, safer sex practices and condom use.



Public Service Announcement in Cameroon
“Sex can wait…my future comes first.”

South Africa is a key example of a country, of a government that has failed its people. Until very recently, the government took no part in the fight against AIDS. Thabo Mbeki, president from 1999 to 2008 refused to believe that HIV causes AIDS and that condoms can prevent infection. This leadership has fueled outlandish beliefs such as that condoms cause AIDS, or that white people are pushing condoms laced with AIDS to wipe out Africans. When asked about the role of the government in the fight against AIDS, one student said, “The president is not very influential considering he stated that he took a shower after having had sex with someone infected with AIDS, and therefore he would not contract the disease.” Here, she is referring to the current president, Jacob Zuma, who publicly stated that showering after sex with an HIV-positive woman would reduce his risk of being infected. A fellow student added, “NGOs are much more active. They have done a much better job fighting AIDS through their provision of important information and items such as condoms and antiretrovirals.”


Incumbent President of South Africa, Jacob Zuma

The picture of life here has changed drastically since AIDS exploded on the scene. While treatment and prevention are improving in some areas, the governments of more conservative countries, such as South Africa, need to step up and face this issue with full force so that HIV/AIDS is no longer a shadow looming over the lives of everyone.

Facts and figures were obtained from AVERT International HIV and AIDS charity, the Global Health Council, USAID, and Elizabeth Pisani’s The Wisdom of Whores.

I would like to recognize Albert Noah-Messomo, an African native of the Beti people in the rainforest of Cameroon. His traditional African-style music was featured during this Podcast. I would like to thank Kurt Kristensen, Sara Levintow, Nikki Pagano, and Rebecca McQuade for their contributions to this Podcast.

Compulsory HIV Testing

No one can argue that HIV testing is a bad thing. Knowing one’s status allows a person to access treatment earlier, change risky behaviors, or rest assured that he/she is indeed HIV negative. With that said, why not make HIV testing mandatory for everyone? Hello, I am Katie Morris and this is The AIDS Pandemic, a podcast hosted by Dr. Dave Wessner, associate professor of biology, and his students at Davidson College.

Compulsory HIV testing—which requires that the entire population, or at least certain high-risk groups, is tested for HIV—has gotten a bad reputation in recent years from human rights activists who argue for a person’s right to choose to know whether or not they have HIV. However, studies have shown that usually, once a person knows he/she is HIV positive he/she will change his/her risky behaviors to avoid transmitting it to anyone else. Would compulsory testing not at least hinder the spread of HIV among populations? I fully support the freedom of choice, however I also support the right to live and if compulsory testing can reduce the number of people dying from AIDS it should at least be considered by policy makers around the globe.

One of the largest barriers to HIV research and prevention programs in the developing world is a lack of knowledge of the specific epidemics in each country. By requiring people to be tested for HIV, the public health community would gain valuable information on how many people are infected and what groups are most at risk, significantly aiding prevention programs. Bill Clinton, the former President of the United States and founder of the Clinton foundation, which funds a great number of HIV/AIDS programs around the world, is an advocate for mandatory testing in developing countries with high HIV prevalence rates. In a statement made to Reuters, he said, "[W]e can save people's lives, and we can reduce the stigma. There is no way we are going to reduce the spread of this epidemic without more testing because 90% of the people who are HIV-positive don't know it." Everyone who is sexually active, injecting drugs, receiving blood transfusions, or breastfeeding is at risk for contracting HIV, regardless of their age, skin color, education, financial status, or sexuality. Therefore in order to increase more individuals’ knowledge of their statuses so that they do not unknowingly spread HIV, testing needs to go beyond voluntary clinics.

In the aforementioned quote, President Clinton made a statement about reducing the stigma around HIV by implementing mandatory testing. This statement is contrary to what many human rights groups argue. Their concern is primarily with confidentiality breaches, especially in the developing world where the poor infrastructure cannot guarantee secure record keeping and adequate training for counselors. While a valid concern, so much of stigma surrounding HIV in the developing world involves testing itself. People are reluctant to be tested because they associate HIV testing with people who are promiscuous, homosexual, or drug users. By requiring everyone to be tested, the stigma associated with those walking into an HIV testing clinic is eliminated. Also, in places like sub-Saharan Africa where many countries have HIV prevalence rates above 5%, mandatory testing has the possibility to normalize being HIV positive. Of course this requires time and the decision by people to be open about their status but there is potential to show that everyone and anyone can contract HIV and that good things—like treatment, support groups, and advocacy opportunities—can result from knowing your status earlier.

Unfortunately, once you get into the implications of such a policy, things do not remain so straightforward. In the developed world, many argue that compulsory testing is simply a waste of money. That same Reuters report found that in order for population-wide mandatory testing to be cost-effective, the prevalence rate should be above 5%. In the United States where HIV prevalence is believed to be less than 0.004%, mandatory HIV testing may not be the most financially wise decision even though the U.S. is one of the few countries that can actually afford to successfully implement a compulsory HIV testing program. It should be noted that there are certain high-risk groups in specific regions of the U.S. with prevalence rates above 5% that could benefit from mandatory testing. However, requiring testing of one group and not another can be considered discrimination and stigmatize or alienate certain people.

In the developing world where, again, many countries, particularly in sub-Saharan Africa, have HIV prevalence rates above 5% and could seemingly benefit from population-wide HIV testing, new issues arise. First and foremost, these countries lack the resources to be able to test everyone. HIV tests are expensive and require sanitary facilities, laboratories, and trained professionals to draw blood. With this blood test, it can take up to three months to obtain results, creating a large loss due to follow-up. Furthermore, what happens next? HIV testing is only beneficial if it is accompanied by proper education and counseling. These are additional costs and require more trained professionals that are difficult to find in the developing world. If a person tests positive, where do they go from there? Will policies be enacted that require the person to disclose their status to their friends, family, or sexual partners? How will this be enforced? What if ART is not available or affordable to the person who tests positive? Their positive test results have just come as a death sentence, which can lead to a fatalistic attitude and discourage behavior change. If a person tests negative, there is a danger of developing a complacent attitude—since he/she does not have the virus, he/she may feel no responsibility to the HIV epidemic.

Although the benefits to compulsory HIV testing are clear, the realities of implementing a population wide mandatory testing campaign around the world make it not the best option at this point in time. In the developed world where prevalence rates are low, the cost of HIV tests outweigh the benefits of finding the few positive people. This might not always be the case in the future with treatment regimens improving and the early-detection of HIV reducing the long-term opt-out costs of ART. In the developing world, infrastructure, financial, and human resource barriers raise concerns to human rights groups and make the implementation of such a program a nightmare. Also, there remains the question of what to do from a policy standpoint for the people who do test positive. Compromises can be made to reap some of the benefits of compulsory testing without requiring all of the necessary resources. First, there are certain groups that should be required to have HIV tests—pregnant mothers to prevent transmission of HIV to their babies, health professionals to reduce the risk to patients, and sex workers in areas like the Netherlands where their profession is regulated. Second, opt-out HIV testing policies (administering an HIV test to everyone except those who specifically ask not to be tested) are a great way to encourage more HIV testing without requiring it. This is more effective in the developed world where people go for annual health check-ups but there are creative ways to bring opt-out to the developing world through mobile clinics strategically placed in markets, farms, churches, or schools. Compulsory HIV testing is a messy topic but that doesn’t mean the discussion should end there. We should continue to find ways to have as many people as possible aware of their HIV status in hopes of slowing the spread of the HIV epidemic.

Katie Morris, & David R. Wessner (2010). Compulsory HIV Testing The AIDS Pandemic

AIDS 2010 - Day 6

The XVIII International AIDS Conference has come to a close. During the final day, summaries of the meeting were presented and the organizers of the next meeting were introduced.

In 2012, the XIX International AIDS Conference will be held in Washington, DC. The meeting is being held in the US for the first time sonic 1990 because the US recently lifted it's ban on the entry of HIV positive people.

I'll write more about this meeting in the next couple weeks. Right now, though, it's time to pack.

AIDS 2010 - Day 5

At this meeting, the official sessions - plenary talks, poster presentations, panel discussions - are only half of the story. For the week of he International AIDS Conference, the city of Vienna has been awash with other events, all related to the conference. It's hard to make time for everything, but I've tried my best!

One day this week, I visited a counseling center for female sex workers in Vienna. The visit was one of several local engagement tours organized by the conference to give participants a closer look at programs related to HIV/AIDS in Vienna. On my tour, I visited Sophie (http://www.sophie.or.at). The director talked to us about the legality of sex work in Austria and the issues faced by sex workers in Vienna.

On another day, I visited a exhibition kf works by Keith Haring, the influential artist who died of AIDS in 1990. The exhibit, at the Kunsthalle Wien, focused on his works from 1978 to 1982. The show was great. I was especially intrigued by the detailed notebooks he kept while painting.

Finally, we attended the AIDS Gala Concert by the Royal Philharmonic Orchestra. They performed works by Mozart, Tchaikovsky, and Beethoven. Quite simply, it was amazing.

Many other events, from film series to dance performances, have been ongoing throughout the week.

AIDS 2010 - Day 3 & 4

The big news at the conference on Tuesday was the announcement of an effective vaginal microbicide. Dr. Abdool Karim and colleagues from South Africa made the announcement to a very enthusiastic crowd. For the first time in the 30 year battle against AIDS, there now is some hope that women may some day be able to control their risk of infection.

In thus study, the researchers provided women in both an urban and a rural area with capsules of a gel containing 1% tenofovir. Other women received capsules containing a placebo. This antiretroviral drug is a nucleoside analog that has been well studies and shown to effectively reduce viral replication. Women were told to apply the gel intra-vaginally no more than 12 hours before having sex, and again no more than 12 hours after having sex. Participants were tested regularly.

After 30 months, women who used 1% tenofovir showed 38% reduction in HIV infections, a significant difference.

The researchers noted this was only a proof of concept study. Additional studies, examining doses, timing, and other factors need to be tested. But these first tests are exciting.

AIDS 2010 - Day 2

Today was the first full day of activities at the XVIII International AIDS Conference. And what a day it was. Again, I'm amazed by the energy and excitement associated with this meeting. And at this year's conference, unlike previous AIDS conferences that I have attended, there seems to be a legitimate sense of optimism.

As we have heard from several speakers, remarkable progress has been made over the past few years. More drugs have been developed and these drugs are available to more people. Thanks to programs like PEPFAR, The Global Fund, and the Clinton Foundation, more people in developing countries are receiving antiretroviral treatment. The progress has been amazing.

But, as former president Clinton noted, this is only the end of the beginning.treatment alone is not the answer. Dr. Sharon Lewin, in a wonderful opening session talk, expertly explained why we cannot rely on treatment alone. First, studies have shown that even the best treatment regimens do not fully restore life expectancy. This, she noted, is not acceptable. Second, sh explained that treatment is not a cure. Viral reservoirs remain in the body during treatment. Virus may remain latent in resting T cells or in various tissues, such as the brain.

So what does this mean? We must continue our prevention efforts. A solution
requires increased treatment, increased testing, and increased prevention efforts.

Tomorrow - a visit to the Global Village at the conference center and a visit to a Vienna site for sex worker education.

Rights here, right now - AIDS 2010

Today marked the opening of the XVIII International AIDS Conference in Vienna, Austria. What strikes me most about this biennial conference is the energy and excitement. People from all over the world gather with a single goal - the end of the AIDS pandemic. Everyone here, from scientists to politicians to educators to activists are passionate about their work and united in their desire.

After being here for only a day, a few themes seem to be emerging. First, this conference feels very much like a conference about and for Eastern Europe. As we heard from several speakers already, Eastern European and Central Asian countries are seeing the fastest growing HIV epidemic. Another theme that has emerged is the need for harm reduction policies. Finally, we have heard about the need for policy based on evidence, not ideology.

I'm looking forward to day 2.

Born HIV Free campaign to end mother-to-child-transmission

“By 2015, let us end the transmission of HIV from mother to child. This is not a dream: we can do it.”

Carla Bruni-Sarkozy,
The Global Fund Ambassador


With that simple statement from Ms. Bruni-Sarkozy as its guiding principle, the Global Fund to Fight AIDS, Tuberculosis, and Malaria has launched Born HIV Free. The goal of this new initiative is straightforward – stop the mother-to-child transmission of HIV. As Ms. Bruni-Sarkozy notes, this goal is achievable. We have at our disposal the means of protecting our children from infection.

When an HIV+ woman becomes pregnant and gives birth, the virus can be transmitted to the infant during gestation, during delivery, or through subsequent breast-feeding. These types of transmission collectively are referred to as mother-to-child transmission. The terms vertical transmission and perinatal transmission also may be used.

We now know that relatively simple and relatively cheat antiviral regimens can dramatically reduce the rate of mother-to-child transmission. In a 1999 study, Dr. Mary Lou Lindegren and colleagues noted that rates of perinatal transmission dropped significantly in concert with zidovudine (AZT) treatment for the mothers. With the development of better drug regimens, these drops in transmission rates have continued. According to the CDC, an estimated 1,650 HIV-infected infants were born in the US in 1991. In 2004, that number had dropped to less than 200.

This success, however, has not been mirrored in developing countries. The causes of this disparity are several-fold. The most important factors affecting the continued problem of mother-to-child transmission of HIV in developing countries include access to treatment and access to testing. In recent years, antiretroviral drugs have become more available throughout the developing world, thanks, in large part, to the influx of money from sources such as the United States PEPFAR program and the United Nation’s Global Fund. Additionally, other groups, most notably the Clinton Foundation, have fought hard to make these drugs more affordable. But we need to do more. Too many HIV+ women still do not have access to the necessary treatments.

In addition to making drugs more available, we also must work diligently to increase the levels of testing. Treatment to prevent perinatal transmission requires that women know their HIV status.

To find out more about the Born HIV Free campaign, please visit their website at http://www.bornhivfree.org. Let’s join Ms. Bruni-Sarkozy in ending the transmission of HIV from mother to child.

National HIV Testing Day

Welcome to this installment of The AIDS Pandemic. June 27, 2010 is National HIV Testing Day. For many people, this news probably is met with ambivalence. We have a day for everything, it seems. So here it is - another day with another name. We shouldn't, though, link National HIV Testing Day with the made-by-Hallmark days. This day should be different.

On National HIV Testing Day, we all should remind ourselves of the vital role testing plays in our continuing efforts to rid the world of HIV/AIDS. According to the CDC, 1.1 million Americans are infected with HIV. Approximately 1 in 5, however, do not know they are infected. This needs to change. When one knows his or her HIV status, he or she is less likely to transmit the virus. Knowing one's status can lead to earlier treatment, and earlier treatment results in better outcomes. For women, knowing one's status can help decrease the rate of mother to child transmission.

National HIV Testing Day is more than just a day marked on the calendar. This day is a reminder to all of us that testing, along with education and prevention, are necessary and interlocked components of our ongoing efforts against this pandemic.

So how can one get tested? Use this helpful testing locator, provided by aids.gov. And tell your friends.