JAIDS Journal of Acquired Immune Deficiency Syndromes:
Efficiencies in AIDS Programming: The Rhetoric and the Realities
Cohn, Jennifer MD; Holtzman, David MD, MSc; Baker, Brook JD
The authors have no funding or conflicts of interest to disclose.
Correspondence to: Jennifer Cohn, MD, MPH, Department of Medicine, Division of Infectious Diseases, University of Pennsylvania, 3400 Spruce Street, 3rd Floor Silverstein, Suite D, Philadelphia, PA 19104.
Finding “efficiencies” in global HIV programs is the buzzword of the hour. This term has peppered speeches of everyone from Global AIDS Ambassador Eric Goosby1 to President Clinton2 and Bill Gates.3 Even UNAIDS is utilizing new frameworks for costing HIV interventions focusing on strategic investments instead of needs-based costing.4 “Efficiency” here is generally taken to mean “do more with less”—save lives with fewer resources and win the war against HIV without funding increases.
Although there are efficiencies to be gained, additional up-front investments are necessary to turn the tide against HIV and save future costs.4–6 It is also important to highlight what efficiency talk avoids: the other 3 “E's”: equity, effectiveness, and empowerment. This commentary will critically examine efficiency rhetoric and discuss achievable efficiencies in treatment and healthcare delivery that also meet equity, effectiveness, and empowerment goals.
WHY EFFICIENCIES NOW?
Political and financial support for global HIV programs accelerated throughout the last decade as investments showed dramatic results.7 Scale-up of antiretroviral treatment (ART) to 6 million people by 20108,9 resulted in a 19% reduction in AIDS-related deaths 2004–2009.9,10 For the first time, new HIV infections plateaued or started to decline in multiple countries, and a 19% decrease in global incidence was observed since the peak in 1999.10 Breakthrough data from the HIV Prevention Trials Network (HPTN) 052 trial has shown ART reduces HIV transmission by 96% in serodiscordant couples.11
Despite these impacts, financial support for HIV programs began to fade in 2009 as both donor fatigue and the effects of the economic crisis began to take their toll and subsequently, efficiency rhetoric gained prominence.7 Efficiency rhetoric resonates with calls for fiscal restraint and cost-effectiveness. Although certain efficiencies would be cost-saving and increase access to HIV care and treatment, others are false efficiencies that will lower costs but threaten existing gains and important equity, effectiveness, and empowerment goals. Worse, some proposed efficiencies simply shroud donor fatigue.
Although there are many useful efficiencies, we will focus on categories where there have been significant recent advances as follows: access to medicines, health care delivery, and health workforce.
Efficiencies in Improving Access to Medicines
The costs of care and treatment for people living with HIV represent a large portion of global HIV funding. PEPFAR spends 53% of its budget on treatment.12 Ensuring medications are procured at the lowest price is one of the best ways of achieving efficiencies. Many mechanisms have been utilized to lower medication pricing, including co-ordinated international regimen planning,13 generic competition,14 and bulk/pooled procurement.15,16
ART regimens purchased in bulk reduces the price by 7%–21%.15 Standardized regimens also allow third-party agents like the Clinton Health Access Initiative to effectively negotiate lower prices with cost savings of 6%–36% for many formulations.15
New Agents and Dose Optimization
It is crucial for academic institutions and pharmaceutical companies to increase research and development of affordable and effective ART. The ART pipeline harbors several exciting prospects that can decrease the costs of first-line and second-line therapy although maintaining quality and effectiveness. Examples include elvucitabine, rilpivirine, and dolutegravir.17,18 Rilpivirine is a nonnucleoside reverse transcriptase inhibitor that maintains effectiveness in the presence of resistance to nevirapine or efavirenz. Clinton Health Access Initiative estimates that its cost may be less than nevirapine leading to potential savings of up to $100 million in the first 2 years of use.19 ART formulations in the pipeline have the possibility of lowering manufacturing costs and extending dosing intervals, further decreasing treatment costs. Unfortunately, some pipeline medications may be abandoned because projected developed country markets are too small to justify the costs of development.
Generic competition decreased ART prices by 23%–498% compared with brand equivalents. Generic purchasing is the strongest predictor of lower prices compared with other price reduction strategies.15,20–22 PEPFAR saved over $320 million in 3 years by increasing use of generic medications from 15% to almost 90%.23 However, there are significant barriers to harnessing the full power of generic competition, most notably the World Trade Organization's Agreement on Trade-Related Aspects of Intellectual Property (TRIPS). TRIPS created a global baseline of enforceable intellectual property rights that impede generic production of newer antiretrovirals (ARVs).14,24 Free trade agreements since TRIPS have further increased barriers to generic competition.25
One strategy to increase generic competition is the medicines patent pool (MPP). The MPP negotiates agreements with patent holders and grants licenses to qualified generic producers who can compete at efficient economies of scale to sell existing and improved ARV formulations throughout the developing world.26,27 The National Institutes of Health and Gilead Company have granted ARV-related licenses to the MPP.
Community-Based Care and Health Workforce Efficiencies
Inadequate testing coverage, poor linkage to care, and loss to follow-up is common.28,29 Connecting patients to care improves adherence and maintains treatment continuity, which increases the efficiency and effectiveness of HIV services. Enhanced adherence improves clinical outcomes and saves costs, given higher prices of second-line and third-line regimens and increased hospitalizations associated with treatment failure.
Several studies have demonstrated that community-based approaches increase adherence, equity, and effectiveness.30,31 A Mozambican program allowed patients who were stable on ART to form community groups to monitor adherence, distribute medications, and liaise with health facilities. These groups enabled facility visits to be spaced to every 6 months, maintained excellent adherence and care outcomes (2% mortality and 0.2% loss to follow-up), and decreased facility-reported workload by 4-fold.30
Task shifting to other health workforce cadres is another way to harness true efficiencies. When supported with appropriate training, supervision, and referral systems, nurses, community health workers, and other cadres improve access to ART by bringing care closer to patients while maintaining good patient outcomes.32,33 Models such as down referral, where ART is initiated at a central facility, and follow-up care is continued at the primary health facility level have been shown to save health care costs although not compromising clinical outcomes.34 HIV care is a perfect setting for task shifting as ART provision is based on standardized and simplified guidelines in low-income countries. Using other cadres of health workers improves workforce density although decreasing the costs because these cadres require less investment in training and earn lower salaries. Task shifting and community-based care models have the important benefits of improving equity by bringing care closer to marginalized groups such as those living in rural areas and increasing patient and community empowerment. Despite these benefits, many country guidelines and donor programs are not sufficiently supporting task shifting for ART initiation and care.35
Even with task shifting, critical shortages of health workers will necessitate significant investments to expand preservice training and increase recurrent expenditures to hire and retain health workers.36,37
Unfortunately, despite evidence supporting the importance of treatment and making treatment models more effective, equitable, and empowering, much of the efficiency discussion has ignored these findings and focused instead on approaches that undermine proven efficiency methods.
Numerous funders and authors have renewed the false dichotomy that pits treatment against prevention by calling for increased focus on prevention at the expense of treatment scale-up. However, before recent positive findings supporting PrEP, microbicides, and male circumcision, evidence supporting stand-alone HIV prevention programs as an effective strategy was modest at best.38,39 Promising and proven prevention strategies need further study, adaptation to context, and scale-up, but not at the expense of treatment, especially in light of recent findings proving the powerful effect of treatment as prevention.
Others have proposed keeping treatment thresholds at 200 CD4 cells per microliter instead of adopting 350 cells per microliter, the new WHO recommendation40 or targeting ART to specific populations, such as sex workers and men who have sex with men.5 Keeping low treatment thresholds will lead to suboptimal care causing more opportunistic infections and worse long-term outcomes compared with patients starting ART earlier41 and perpetuate inequities between rich and poor.
Moreover, starting ART at lower CD4 counts misses an important opportunity to maximize the benefits of ART as a potent prevention tool. Viral load is the most important factor influencing infectivity. Evidence from multiple studies suggests that increased use of ART leads to decreases in the community viral load and a subsequent decrease in HIV incidence.42,43 Choosing to start ART at lower CD4 counts forgoes the chance to lower the community viral load and realize ART's prevention benefits.
The argument that ART is not cost-effective detracts attention from the more pressing issue of insufficient funding for all global health programs, including HIV. A growing body of evidence shows that although greatly scaled-up ART provision is associated with higher up-front costs, it is cost-effective in the mid term and long term.44,45 Efficiency rhetoric should not shroud donor fatigue and fear over future costs. Likewise, cost-effectiveness analyses that value lives of people in poor countries less than those in rich cannot be tolerated.
Although spending resources wisely is critical, we challenge the notion that efficiencies are a magic bullet. We can get more out of every health dollar and it will be critical to monitor key outcome measures that are focused on patient and community wellbeing to ensure quality. The reality is that it will take increased political and financial commitments now as we struggle to gain control over global HIV.
We are at a crucial junction where turning to false efficiencies that focus only on reducing costs or slowing scale-up will lead to a long war of attrition and lost momentum where HIV-positive people living in developing countries will pay with their lives. Instead, focusing on true efficiencies to reach scale-up that is equitable, empowering, and effective will help reverse the pandemic.
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