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AIDS
Editorial
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Comparative effectiveness research in the USA
For Research on the Comparative Effectiveness of Medical Treatments see http:// www.cbo.gov/ftpdocs/88xx/ doc8891/12-18-Comparative Effectiveness.pdf
The USA leads the world in generating research evidence but lags behind other countries in translating those findings into better health for its citizens. Thus, President Obama’s US$1·1 billion stimulus for research that compares the effectiveness of different health-care interventions is welcome. Research priorities identified by the respected Institute of Medicine will be addressed by new studies or by syntheses of existing data, using programmes at the Agency for Healthcare Research and Quality (AHRQ), National Institutes of Health, and the Department of Health and Human Services. Comparative effectiveness research enables health-care providers and consumers to make better-informed choices. With evidence for only half of health-care decisions, there is a substantial need for additional information. Unfortunately, previous efforts by AHRQ to meet this need were harshly opposed, and already strong special interest groups, united by ignorance, fear, and greed, are criticising the initiative. Clearly, the way forward will not be easy. But though the voice of evidence is often lonely, it is never alone: the aspiration of better care from effectiveness
research is shared by the US Cochrane Center and by enlightened groups of stakeholders throughout the USA. Sadly, the debate so far has been on cost rather than improved health or safety. Unsurprising, perhaps, since spending on health in the USA passed $2 trillion in 2007 (16% of gross domestic product) and continues to rise without delivering proportional improvements in outcomes. But to reduce effectiveness to cost alone, even though such research is likely to be largely selffinancing, shows the extent to which health care has lost direction in the USA, and it perverts the principles of evidence-based practice, which emphasise benefits and harms to patients. Adding a human dimension to this debate is essential in a country where each year up to 98 000 die from iatrogenic errors and 1·5 million patients have a preventable adverse drug reaction. Comparing effectiveness is only the first step. To benefit patients, evidence must be communicated and incorporated into care. Success depends on winning hearts as well as minds; not a shameful charade of carrot and stick financial incentives. ■ The Lancet
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China’s evolving response to HIV/AIDS
See World Report page 707
For the state media report see http://news.xinhuanet.com/ english/2009-02/17/content_ 10836423.htm For the Human Rights Watch report see: http://www.hrw.org/ en/reports/2008/12/09/ unbreakable-cycle-0
694
Over the past decade, China’s response to HIV/AIDS has transformed from denial and inertia to pragmatic prevention and treatment programmes. Still, massive challenges remain for the country. On Feb 17, official state media reported that in 2008 HIV/AIDS was China’s leading killer among infectious diseases for the first time. Under-reporting means that accurate figures on the country’s epidemic are hard to come by. However, UNAIDS estimates that around 700 000 people are living with HIV/AIDS in China. China has committed resources and energy to tackle the epidemic, which deserve praise. In 2003, it launched its nationwide “four frees, one care” programme: free HIV testing; free counselling and antiretrovirals for patients in rural regions; free medication for all pregnant HIV carriers; free education for AIDS orphans; and care for impoverished AIDS patients. China’s prevention efforts have also responded well to changes in the country’s main mode of HIV transmission. Initially, the government introduced blood screening to prevent blood-borne
infections and needle-exchange programmes to reduce infections in injecting drug users. More recently, it has launched nationwide awareness and safe-sex campaigns to address heterosexual transmission—now the main mode of HIV transmission in China. But, even with good HIV programmes, the size of the country and its population and the decentralised system of government make universal access to testing, treatment, and prevention, and the communication of public-health messages, extremely difficult. Cultural sensitivities to discussing sex and the stigma attached to homosexuality also make communicating the risks of HIV infection an immense challenge. And human-rights issues remain a problem. A recent report by Human Rights Watch found that drug rehabilitation centres in the Guangxi province subject users to abusive and degrading treatment and fail to provide them with HIV prevention and treatment. The success of China’s HIV-control efforts will depend on how the country’s response continues to evolve to meet these challenges. ■ The Lancet www.thelancet.com Vol 373 February 28, 2009
Jupiter Images
Comparative effectiveness research in the USA
For Research on the Comparative Effectiveness of Medical Treatments see http:// www.cbo.gov/ftpdocs/88xx/ doc8891/12-18-Comparative Effectiveness.pdf
The USA leads the world in generating research evidence but lags behind other countries in translating those findings into better health for its citizens. Thus, President Obama’s US$1·1 billion stimulus for research that compares the effectiveness of different health-care interventions is welcome. Research priorities identified by the respected Institute of Medicine will be addressed by new studies or by syntheses of existing data, using programmes at the Agency for Healthcare Research and Quality (AHRQ), National Institutes of Health, and the Department of Health and Human Services. Comparative effectiveness research enables health-care providers and consumers to make better-informed choices. With evidence for only half of health-care decisions, there is a substantial need for additional information. Unfortunately, previous efforts by AHRQ to meet this need were harshly opposed, and already strong special interest groups, united by ignorance, fear, and greed, are criticising the initiative. Clearly, the way forward will not be easy. But though the voice of evidence is often lonely, it is never alone: the aspiration of better care from effectiveness
research is shared by the US Cochrane Center and by enlightened groups of stakeholders throughout the USA. Sadly, the debate so far has been on cost rather than improved health or safety. Unsurprising, perhaps, since spending on health in the USA passed $2 trillion in 2007 (16% of gross domestic product) and continues to rise without delivering proportional improvements in outcomes. But to reduce effectiveness to cost alone, even though such research is likely to be largely selffinancing, shows the extent to which health care has lost direction in the USA, and it perverts the principles of evidence-based practice, which emphasise benefits and harms to patients. Adding a human dimension to this debate is essential in a country where each year up to 98 000 die from iatrogenic errors and 1·5 million patients have a preventable adverse drug reaction. Comparing effectiveness is only the first step. To benefit patients, evidence must be communicated and incorporated into care. Success depends on winning hearts as well as minds; not a shameful charade of carrot and stick financial incentives. ■ The Lancet
Getty Images
China’s evolving response to HIV/AIDS
See World Report page 707
For the state media report see http://news.xinhuanet.com/ english/2009-02/17/content_ 10836423.htm For the Human Rights Watch report see: http://www.hrw.org/ en/reports/2008/12/09/ unbreakable-cycle-0
694
Over the past decade, China’s response to HIV/AIDS has transformed from denial and inertia to pragmatic prevention and treatment programmes. Still, massive challenges remain for the country. On Feb 17, official state media reported that in 2008 HIV/AIDS was China’s leading killer among infectious diseases for the first time. Under-reporting means that accurate figures on the country’s epidemic are hard to come by. However, UNAIDS estimates that around 700 000 people are living with HIV/AIDS in China. China has committed resources and energy to tackle the epidemic, which deserve praise. In 2003, it launched its nationwide “four frees, one care” programme: free HIV testing; free counselling and antiretrovirals for patients in rural regions; free medication for all pregnant HIV carriers; free education for AIDS orphans; and care for impoverished AIDS patients. China’s prevention efforts have also responded well to changes in the country’s main mode of HIV transmission. Initially, the government introduced blood screening to prevent blood-borne
infections and needle-exchange programmes to reduce infections in injecting drug users. More recently, it has launched nationwide awareness and safe-sex campaigns to address heterosexual transmission—now the main mode of HIV transmission in China. But, even with good HIV programmes, the size of the country and its population and the decentralised system of government make universal access to testing, treatment, and prevention, and the communication of public-health messages, extremely difficult. Cultural sensitivities to discussing sex and the stigma attached to homosexuality also make communicating the risks of HIV infection an immense challenge. And human-rights issues remain a problem. A recent report by Human Rights Watch found that drug rehabilitation centres in the Guangxi province subject users to abusive and degrading treatment and fail to provide them with HIV prevention and treatment. The success of China’s HIV-control efforts will depend on how the country’s response continues to evolve to meet these challenges. ■ The Lancet www.thelancet.com Vol 373 February 28, 2009