Tuesday, October 26, 2010

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.

Tuesday, October 19, 2010

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.

Thursday, October 14, 2010

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