Elsevier

The Lancet

Volume 359, Issue 9320, 25 May 2002, Pages 1851-1856
The Lancet

Public Health
HIV prevention before HAART in sub-Saharan Africa

https://doi.org/10.1016/S0140-6736(02)08705-6Get rights and content

Summary

Data on the cost-effectiveness of HIV prevention in sub-Saharan Africa and on highly active antiretroviral therapy (HAART) indicate that prevention is at least 28 times more cost effective than HAART. We aim to show that funding HAART at the expense of prevention means greater loss of life. To maximise health benefits, the next major increments of HIV funding in sub-Saharan Africa should be devoted mainly to prevention and to some non-HAART treatment and care. Funds should be allocated to HAART primarily for demonstration projects that will help prepare for scaled-up HAART provision following broad population coverage by prevention programmes. UNAIDS and the London School of Hygiene and Tropical Medicine recently estimated that at least US$9·2 billion annually is required to mount an appropriate response to the HIV pandemic, including substantial funding for HAART. To date, US$1·96 billion has been committed to the newly-established UN Global Fund to Fight AIDS, Tuberculosis, and Malaria. It is a moral imperative that expanded programmes to control HIV be implemented without delay, and that the goal of US$9·2 billion or more in annual spending be attained as rapidly as possible. The findings and recommendations of this analysis pertain to the phasing in of additional HIV-related activities during the current period of improved but inadequate funding.

Section snippets

An effective prevention and treatment response

Two recent studies estimated the cost of an effective response.6, 7 One concluded that $9·2 billion would be needed annually.6 This estimate is roughly consistent with an earlier estimate of at least $7·5 billion annually.7 The higher figure of $9·2 billion represents 0·044% of the combined gross national product of the 22 wealthy donor countries constituting the Development Assistance Committee of the Organization for Economic Cooperation and Development (OECD).7 As indicated by their

How could money be best spent in the interim?

While the world debates how to achieve the full $9·2 billion needed, we need to decide how the next incremental contributions shall be spent.

A dominant theme heard from many policy makers and analysts is that treatment and prevention must go hand-in-hand. This rhetoric often fails to distinguish between treatment of opportunistic infections and palliative care, which is inexpensive and often highly cost effective,9 and HAART, which is both more costly and more effective. Combining the two under

Does prevention work?

HIV control efforts in Africa have centered on prevention since the beginning of the pandemic. Since incidence has increased dramatically, it would appear that spending more on prevention is a dubious choice. We believe that prevention programmes should be assessed more frequently and more rigorously. Some, such as mass communication and social marketing programmes, are particularly difficult to assess and others have not been assessed in a sufficient number of settings. Nevertheless, as

Limitations to the case for prevention

We recognise a number of limitations to this analysis. First, the analysis does not account for the value of pilot studies that assess the benefits, costs, and safety of delivering HAART in selected settings. This could have the important advantage of identifying the best means for delivering HAART in resource-poor settings. Thus, after expanded funding of prevention, HAART provision could be scaled up more rapidly, since best practices would already have been identified.

Second, we focus on the

Prevention and the rule of rescue

We believe other reasons exist to advocate the primacy of prevention. As the price drops, the pressure to spend money on HAART may become almost irresistible, for the best of humanitarian reasons. As will be discussed in more detail below, the “rule of rescue” dictates that more resources will be made available for identified sufferers than for present or future sufferers who are statistical abstractions. For this reason it is perhaps inevitable that more will be spent for treatment than is

But is it ethical?

There exists an ethical imperative based on principles of simple justice for the rich countries to mount an effective response to the HIV pandemic. This should include scaled-up prevention, treatment of opportunistic infections, care for the ill and for orphans, and the provision of HAART wherever and whenever this can be done safely. Based on the current actions of the OECD countries, it is sensible to assume that a fully scaled-up response is at least a few years away. It is also conceivable

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