- Email: [email protected]
AIDS: an opportunity not to be lost
147
than twelve months. During one year in Chiang Mai, Thailand, 10% of one group of prostitutes seroconverted each month. Some governments have turned a blind eye to HIV at the very time when prevention would have been most cost-effective; others have provided few or no services. Another factor is that some of those most at risk, such as prostitutes, are naturally suspicious of government
EDITORIALS
programmes.
AIDS:
an
opportunity
not to be lost
The VIII International Conference on AIDS, beginning in Amsterdam this weekend, will document a calamitous failure in preventive medicine. The spread of human immunodeficiency virus (HIV) infection is outrunning our ability to deal with it. Efforts at control, with one or two exceptions, are not
having any impact. AIDS is still a new disease; the largest number of deaths and the greatest number of new infections are ahead of us. Computer models show that, when the number of people infected doubles every three years (an average time for heterosexual spread), thirty years may elapse between arrival of the first cases in the community and infection of 1% of the population. Later it will take only the same three years for prevalence to double from, say, 10% to 20%. The best opportunities for HIV control have already slipped from our grasp. We were not even aware of the disease by the time spread reached the 1% level in much of East Africa. However, since the mid-1980s, we have known enough to set sound public health policies in education, the supply of condoms, and the control of the other sexually transmitted diseases (genital ulcers, in particular, are important risk factors for HIV transmission). The effectiveness of each possible intervention is weak but all three together should be synergistic.! Given the right policies and sufficient resources, the epidemic could be slowed. Unfortunately, none of the interventions in the third world is being planned on a scale large enough to have a substantial impact on the
epidemic.
Among prostitutes, gay men, and intravenous drug users, the doubling time of the epidemic can be less
The WHO Global Programme on AIDS (WHO/ GPA) now receives over$100 million a year from developed countries. It has defined the scientific issues but, as an intergovernmental agency, it has been seriously constrained by having to respond solely to National requests. government programmes commonly emphasise screening of the blood supply, whereas more powerful engines of infection such as sickness among prostitutes go unchecked. Nongovernment organisations (NGOs) have shown greater flexibility and have pioneered interventions among groups practising high-risk behaviours.2 Communities care about their own welfare and future, but have insufficient resources to make an epidemiologically significant impact. Some national AIDS committees themselves slow down needed action; after months of discussion a decision may be blocked by someone who disapproves of condoms or denies the reality of prostitution. Government reporting of AIDS cases can be a meaningless ritual. In India, for example, just over 100 cases have been reported to V,7]HO/GPA, but an estimated 1 million people are HIV-positive. In Bombay alone there are at least 100 000 prostitutes living in great poverty and cruelly exploited; they have an average of 5 partners a night, are a group clearly in need of help, and yet, apart from some minuscule NGO efforts, nothing has been done. At least 30% of these women are HIV-positive33 and Bombay probably represents the most rapid generator of new HIV cases anywhere on earth. With a new epidemic that is growing exponentially, even a poor programme today would be better than a good one tomorrow. By the end of this decade there may be as many HIV-positive cases in Asia as in Africa. An effective vaccine is unlikely to be in production for a decade or more, and by then the number of infected persons world wide will have doubled several times. In the early 1980s accumulation of new knowledge about AIDS was rapid and annual international conferences had an important role. The VIII conference was to have been held in Boston, but this venue was cancelled as a protest against the discriminatory polices of the US immigration authorities. Was there really any need for the substitute meeting in Amsterdam? It will cost more than ten times the total WHO/GPA budget for condoms since the programme was first launched. We know what to do: the difficulty is to get the resources and to put them in the right place.
148
The one certainty is that more of the same will not do. New mechanisms must be devised to pass large sums of money and technical assistance to groups working outside national government control. Already such changes are occurring. Last year, USAID sponsored a$169 million five-year programme (AIDSCAP), working extensively with NGOs and the private sector. European governments and the European Community need access to a similar structure. The Wellcome Foundation lately launched its Positive Action Programme, which shows leadership in this area. The new HIV/AIDS NGO Support Programme will also be able to fill important gaps. The era of mega-conferences should now end. The overwhelming needs are rapid project implementation, large-scale education and condom distribution, and control programmes for sexually transmitted diseases. This strategy has a genuine potential to slow this terrible epidemic. M, Anderson R, Boily C. Slowing the spread of human immunodeficiency virus in developing countries. Lancet 1991; 338:
1. Potts
608-13. 2. Crane SF, Carswell
JW. A review and assessment of non-governmental
organisation-based STD/AIDS education and prevention projects for marginalized groups. Health Educ Res Theory Pract 1992; 7: 175-94. 3.
Ramalingaswami V. India: national plan for AIDS control. Lancet 1992; 339: 1162-63.
Discounting health care: only a matter of timing? Economic analyses are playing an increasingly important part in decisions about the allocation of limited resources between health care interventions. Economic appraisal of treatments and technologies is seen as a useful way to identify the most efficient methods of improving health. These appraisals compare the total costs and the health benefits of various programmes. Superficially the main issues are to decide which costs and benefits to include and how to measure them. However, underneath the surface a debate has opened up over the use of a particular technique known as discounting. As with most projects, the costs and benefits of health programmes do not all occur at once but are spread over time. For example, a mass vaccination programme may have to be paid for in the first few years but, if effective, the benefits will be felt several years in the future. How are the costs or benefits with different timings to be added up and programmes compared? Traditionally costs are not simply added together, because the value of money varies over time. Thus £ 100 ($188) today, if invested at a 5% interest rate (adjusted for inflation) will grow to C128 in five years; conversely 128 received in five years’ time is equivalent to (when discounted) clot today. If offered the choice of a gift of [1 100 now or 100 in five years, we would choose to receive the money now. Consequently, before aggregation, costs are adjusted
take into account their timing. The further in the future the cost, the more heavily it is discounted and the less expensive it appears; 128 in ten years time has a credit value of only 79. Most of us are not indifferent to the timing of costs and benefits: we prefer to receive benefits now and to postpone costs. This "positive time preference", whereby the future is less heavily weighted, has an important influence on individual behaviour: young smokers dismiss the risk of disease late in life in favour of the perceived current benefits of smoking. Because of the similarity between discounting of the future for monetary and psychological reasons, economists use the interest rate as a proxy for people’s rate of time preference. In economic appraisal it is therefore recommended that not only costs but also measures of health benefit be discounted before they are added and programmes compared.! A life-year gained or increased mobility in a patient today will be more highly weighted than in five years’ time. Despite the near universal practice of discounting, there is little agreement about which rate of discount to use. In the UK, a rate of 5-6% has been used by government; the US Congressional Budget Office uses 2% whereas the Office of Management and Budget Policy uses 10%. In addition, there are subtle differences in the way that increases in life expectancy are discounted. The Swedish health economist Johannesson showed that, although these differences are seldom made explicit, they can result in large variations in the results even when the same discount rate is used.2 Because of the way they treat life expectancy, some of these methods set a higher value on added life years in the old than in the young and in men than in women. Johannesson argues that there should be more consistency in techniques to allow to
comparison. The whole practice of discounting health benefits has now been challenged,3,4 partly because of the effect discounting has on comparison of programmes with different time profiles. For example, because their benefits are delayed, preventive strategies often compare badly with acute care, for which the effects are more immediate. Similarly, investments in for the health of future generations seem programmes to generate negligible benefits. The myopia implicit in discounting shifts the costs of health to the future.5 The new journal Health Economics includes a debate in which UK Department of Health economic advisers question whether non-monetary health benefits should be discounted at the same rate as variables expressed in monetary terms, or indeed at all. 3,6 Many of the underlying assumptions used to justify discounting are shown for technical reasons not to apply to health benefits.3,4 Discounting in the appraisal of public programmes is further criticised because it is founded on the belief that policy decisions should mirror the preferences of individuals and so incorporate positive time preferences.’ The counterargument is that selfish myopia is not a rational basis
than twelve months. During one year in Chiang Mai, Thailand, 10% of one group of prostitutes seroconverted each month. Some governments have turned a blind eye to HIV at the very time when prevention would have been most cost-effective; others have provided few or no services. Another factor is that some of those most at risk, such as prostitutes, are naturally suspicious of government
EDITORIALS
programmes.
AIDS:
an
opportunity
not to be lost
The VIII International Conference on AIDS, beginning in Amsterdam this weekend, will document a calamitous failure in preventive medicine. The spread of human immunodeficiency virus (HIV) infection is outrunning our ability to deal with it. Efforts at control, with one or two exceptions, are not
having any impact. AIDS is still a new disease; the largest number of deaths and the greatest number of new infections are ahead of us. Computer models show that, when the number of people infected doubles every three years (an average time for heterosexual spread), thirty years may elapse between arrival of the first cases in the community and infection of 1% of the population. Later it will take only the same three years for prevalence to double from, say, 10% to 20%. The best opportunities for HIV control have already slipped from our grasp. We were not even aware of the disease by the time spread reached the 1% level in much of East Africa. However, since the mid-1980s, we have known enough to set sound public health policies in education, the supply of condoms, and the control of the other sexually transmitted diseases (genital ulcers, in particular, are important risk factors for HIV transmission). The effectiveness of each possible intervention is weak but all three together should be synergistic.! Given the right policies and sufficient resources, the epidemic could be slowed. Unfortunately, none of the interventions in the third world is being planned on a scale large enough to have a substantial impact on the
epidemic.
Among prostitutes, gay men, and intravenous drug users, the doubling time of the epidemic can be less
The WHO Global Programme on AIDS (WHO/ GPA) now receives over$100 million a year from developed countries. It has defined the scientific issues but, as an intergovernmental agency, it has been seriously constrained by having to respond solely to National requests. government programmes commonly emphasise screening of the blood supply, whereas more powerful engines of infection such as sickness among prostitutes go unchecked. Nongovernment organisations (NGOs) have shown greater flexibility and have pioneered interventions among groups practising high-risk behaviours.2 Communities care about their own welfare and future, but have insufficient resources to make an epidemiologically significant impact. Some national AIDS committees themselves slow down needed action; after months of discussion a decision may be blocked by someone who disapproves of condoms or denies the reality of prostitution. Government reporting of AIDS cases can be a meaningless ritual. In India, for example, just over 100 cases have been reported to V,7]HO/GPA, but an estimated 1 million people are HIV-positive. In Bombay alone there are at least 100 000 prostitutes living in great poverty and cruelly exploited; they have an average of 5 partners a night, are a group clearly in need of help, and yet, apart from some minuscule NGO efforts, nothing has been done. At least 30% of these women are HIV-positive33 and Bombay probably represents the most rapid generator of new HIV cases anywhere on earth. With a new epidemic that is growing exponentially, even a poor programme today would be better than a good one tomorrow. By the end of this decade there may be as many HIV-positive cases in Asia as in Africa. An effective vaccine is unlikely to be in production for a decade or more, and by then the number of infected persons world wide will have doubled several times. In the early 1980s accumulation of new knowledge about AIDS was rapid and annual international conferences had an important role. The VIII conference was to have been held in Boston, but this venue was cancelled as a protest against the discriminatory polices of the US immigration authorities. Was there really any need for the substitute meeting in Amsterdam? It will cost more than ten times the total WHO/GPA budget for condoms since the programme was first launched. We know what to do: the difficulty is to get the resources and to put them in the right place.
148
The one certainty is that more of the same will not do. New mechanisms must be devised to pass large sums of money and technical assistance to groups working outside national government control. Already such changes are occurring. Last year, USAID sponsored a$169 million five-year programme (AIDSCAP), working extensively with NGOs and the private sector. European governments and the European Community need access to a similar structure. The Wellcome Foundation lately launched its Positive Action Programme, which shows leadership in this area. The new HIV/AIDS NGO Support Programme will also be able to fill important gaps. The era of mega-conferences should now end. The overwhelming needs are rapid project implementation, large-scale education and condom distribution, and control programmes for sexually transmitted diseases. This strategy has a genuine potential to slow this terrible epidemic. M, Anderson R, Boily C. Slowing the spread of human immunodeficiency virus in developing countries. Lancet 1991; 338:
1. Potts
608-13. 2. Crane SF, Carswell
JW. A review and assessment of non-governmental
organisation-based STD/AIDS education and prevention projects for marginalized groups. Health Educ Res Theory Pract 1992; 7: 175-94. 3.
Ramalingaswami V. India: national plan for AIDS control. Lancet 1992; 339: 1162-63.
Discounting health care: only a matter of timing? Economic analyses are playing an increasingly important part in decisions about the allocation of limited resources between health care interventions. Economic appraisal of treatments and technologies is seen as a useful way to identify the most efficient methods of improving health. These appraisals compare the total costs and the health benefits of various programmes. Superficially the main issues are to decide which costs and benefits to include and how to measure them. However, underneath the surface a debate has opened up over the use of a particular technique known as discounting. As with most projects, the costs and benefits of health programmes do not all occur at once but are spread over time. For example, a mass vaccination programme may have to be paid for in the first few years but, if effective, the benefits will be felt several years in the future. How are the costs or benefits with different timings to be added up and programmes compared? Traditionally costs are not simply added together, because the value of money varies over time. Thus £ 100 ($188) today, if invested at a 5% interest rate (adjusted for inflation) will grow to C128 in five years; conversely 128 received in five years’ time is equivalent to (when discounted) clot today. If offered the choice of a gift of [1 100 now or 100 in five years, we would choose to receive the money now. Consequently, before aggregation, costs are adjusted
take into account their timing. The further in the future the cost, the more heavily it is discounted and the less expensive it appears; 128 in ten years time has a credit value of only 79. Most of us are not indifferent to the timing of costs and benefits: we prefer to receive benefits now and to postpone costs. This "positive time preference", whereby the future is less heavily weighted, has an important influence on individual behaviour: young smokers dismiss the risk of disease late in life in favour of the perceived current benefits of smoking. Because of the similarity between discounting of the future for monetary and psychological reasons, economists use the interest rate as a proxy for people’s rate of time preference. In economic appraisal it is therefore recommended that not only costs but also measures of health benefit be discounted before they are added and programmes compared.! A life-year gained or increased mobility in a patient today will be more highly weighted than in five years’ time. Despite the near universal practice of discounting, there is little agreement about which rate of discount to use. In the UK, a rate of 5-6% has been used by government; the US Congressional Budget Office uses 2% whereas the Office of Management and Budget Policy uses 10%. In addition, there are subtle differences in the way that increases in life expectancy are discounted. The Swedish health economist Johannesson showed that, although these differences are seldom made explicit, they can result in large variations in the results even when the same discount rate is used.2 Because of the way they treat life expectancy, some of these methods set a higher value on added life years in the old than in the young and in men than in women. Johannesson argues that there should be more consistency in techniques to allow to
comparison. The whole practice of discounting health benefits has now been challenged,3,4 partly because of the effect discounting has on comparison of programmes with different time profiles. For example, because their benefits are delayed, preventive strategies often compare badly with acute care, for which the effects are more immediate. Similarly, investments in for the health of future generations seem programmes to generate negligible benefits. The myopia implicit in discounting shifts the costs of health to the future.5 The new journal Health Economics includes a debate in which UK Department of Health economic advisers question whether non-monetary health benefits should be discounted at the same rate as variables expressed in monetary terms, or indeed at all. 3,6 Many of the underlying assumptions used to justify discounting are shown for technical reasons not to apply to health benefits.3,4 Discounting in the appraisal of public programmes is further criticised because it is founded on the belief that policy decisions should mirror the preferences of individuals and so incorporate positive time preferences.’ The counterargument is that selfish myopia is not a rational basis